Annual review and planning meeting on onchocerciasis control and surveillance activities in the Ex-ocp countries: pregress report 2008 and plan of actions and budget 2009 (Ghana, Sierra Leone)

Organisation mondiale de la Sant6 REGION DE L'AFRIQUE Programme africaln de lutte contre t,Onchocercose 91.B.1-q49, Ouagadougou 0i, Burkina fasotet: (226) 50 34 29 s3; Ig . 29 59; 50 34 29 60; 50 34 36 45146Fax: (226)503428 75; 50 3+ 3647' -- ANNUAL REVIEW AND PLANNING MEETING ON ONCHOCERCIASIS CONTROL AND SURVEILLANCE ACTIVITIES IN THE EX.OCP COUNTRIES PROGRESS REPORT 2OO8 AND PLAN OF ACTIONS AND BUDGET 2OOg G A LE A. GHANA SUMMARY REPORT OF NOCPAITDS ACTIYITIES IN 2OO8 1.0: Introduction The year 2008 got underway with series of planned activities both for the sIZ and non-SIZ areas following recommendations from surveittur.. and research activities conducted inyear 2007 as follows; o Identify and map out all farm-huts, hamlets and fishing communities for Ivermectintreatment o Ensure integration of GDTI into mainstream NTD shategyo Monitor Onchocerciasis recrudescencethrough o Strengthened cross border activities,niitt togo NOCPo Employment of limited larvicidal activities it t igr, breeding areas to reduce black flypopulation and nuisance o Improve supervision and monitoring of CDTI activities at all levels of the health systemt Improve partnership with partners and collaborators such as Sight Savers International (ssl)and communities to faciritate programme ownership and sustainabirityo Build capacity of regional staff to conduct surveillance activities for evaluation ofprogrammes o Conduct operational research into motivation of CDDs 2.0: Meetings 2.1: Collaborative Meetings with Sight_Savers, Ghana As a way of improving oncho control activities in Ghana, a 7-member working groupcomprising technical staff from both sight-Savers Intemational and the Ghana oncho controlProgramme were put together under the tutelage of Mr. Simon Bush, Regional Director of Sight-Savers operations in west Africa. The terms of reference were as follows:o Identify the areas of weaknesses in the national oncho control efforts and suggest ways ofaddressing them. o Determine any other ways that would improve the performance of oncho control in Ghana. The group met 6 times and summed up weaknesses identified in the implementation of activitiesAS; o Plannins: It was identified that planning for oncho activities were not well integrated at alllevels since there is no policy-as weli as contractual agreement from the Ghana Healthservice used in assessing the performance of regions and districts towards the achievementof the therapeutic target of 85% as pertains in ihe other programmes. In effect it is not apriority' Packaging oncho with the Niglected rropical Dir.u.., may be the way forward.o Supervision: This was identified as one of the ru;o, weaknesses oith. programme. SeveralcDDs, after the initial training, receive inadequate support from health"workers during 2 implementation of activities. The low morale and non-commitment of health workers areresponsible for this performance, and o Late Reporting 2.2: Planning and Review Meeting The second national planning and review meeting was organized from the 26rh -30,h May2008 at hotel Splendor, Kumasi. It was attended by Refronal ani Depu,v nrg;rul Directors ofHealth and their representatives, Regional oncho coo-rdinators, representatives from researchinstitutions, Directors from Ghana Hea]fr service heaffin.., and programme Managers ofBuruli Ulcer control Programme and Yaws Eradication programme. pltn"i, such as SightSavers International, ApOC and WHO were also present. The rationale of the meeting was to o Explore further, in collaboration with stakeholders, challenges faced by the National Onchocontrol programme in the implementation of activiiies and suggest ways of improving themo Develop strategic plans for addressing key issues identified in the regions and districts During the main discussions and plenary sessions participants debated and brain stormed on the key issues that emerged from the presentations and developed action steps for addressing the challenges identified, thus; CDTI. 2 ) 4 eDDs working in se-veral communities: It was agreed that as many CDDs as possible shouldbe recruited for each community in order to le-ssen cDD workload which directly affectsdemands for improved incentives. The present recommendation was to have one cDD workon a population of approximately 100 persons. Manied CDDs, especially females, wereprefered to their male counterparts since their continued stay in the community i, assured. communities with links to hamlets: Participants resolvld that all hamleis and fishing communities were to be mapped immediately for CDTI. This implies identifying and listingall hamlets and fishing communities, recruiting CDDs and supplying registers and otherlogistics to facilitate implementation of CDTi activities like- censu"s taking, Ivermectindistribution , etc. any merged communities were therefore to be separated. CDD incentives: Allowances to CDDs are very sensitive, and so, needed further discussions and consultations' Members resolved the way iorward was to discuss with communities for adetermination of the form of incentives it desired to offer its cDDs. In the meantimeprogrammes were to collaborate with the much endowed programmes like malaria, TB orHIV/AIDS for a harmonization of incentives. Treatment period should be changed to suit the social lifestyles of communities, especially prior to the raining season5. High Ivermectin refusals: Apart from intensifying social mobilization activities participants suggested operational research into reasons ofdrug refusals to reinforce key messages. It was also suggested that the programme col laborates with organizations with expertise in to communication and behavioral change to support the regions ? 67 Shortaee of Ivermectin: Regions and districts were urged to make accurate forecast ofIvermectin tablets required to treat all eligible persons in-order to prevent such occurrences.As such it was suggested that regions revisit thlir population estimates and project using theregistered census data' Ad hoc distributions by ,rlionut officers were also io ,,op and stepstaken to mop up ail reft-over drugs for storage at the regionar medicar stores.Poor Data management: It was agreed that the "apacities of all data managers be built toensure that mechanisms for the collection, analysis, storage, easy retrieval and disseminationexist. In all cases back ups of ail data coilected must be done. Non-standardized Measurine Poles: the preparation and distribution of measuring pole!should be devolved to the regions. The national office shourd collaborate with rhe regions toensure standardization across the country. :Thereistheneedtosub-dividetheareasintosmaller units and put cDDs in charge. The example of cong o Brazzaville was sited as a possible example to follow. l0' Lack of fundine for non-SIZ areas: The national office was urged to collaborate and inte$atewith other programmes as well as strengthen advocacy for increased financial support. E ntomo logical S urveil lance 8 9 I Nuisance control: It was recommended that the national office support regions to undertakelimited residual Iarviciding in areas noted for complaints of black fly nuisance. Specificbreeding sites on the white and Black volta, Asukawkaw, pra, pru and Kulpawn river basins were to be identified for larviciding. capacity Buildine of regional staff: It was recommended that the capacities of regionalBiologists be built to support entomological surveillance activities in their regions bymonitoring fly collection and dissection. :TheneedtoeffectivelycolIaboratewithlocaI research institutions like Noguchi and KCCR to provide research support to the nationalprogrammes in surveiilance activities was highry recommended. 2 3 Epidemio lo gical S urvey s 2 J Non-involvement of regions in epidemiological and entomological surveillance. It wasobserved that expertise in the requisite surveillance fields abounds, and that, steps must betaken to bring all on board including institutions like Noguchi and KCCR.REMo in forest areas. The meeting recommended an oncho REMO be done immediately to reveal the real picture in the forest areas for treatment. Inadequate sclera-corneal punches: The oncho programme management was urged toprocure adequate skin snip equipment to facilitate epideiological surveys in the regions. 4 S up ervision, Mo nttoring and Reporting l' Empowerment of communities: It was suggested that communities be empowered throughtraining to undertake monitoring and supervision of GDTI activities in what is popularly known in Oncho circles as .community self_monitoring,.2' Integrated monitoring: Regions and districts were encouraged to promote integrated monitoring as part of efforts to integrate programmes and ensure efficient use of resources of all programmes. J The national office to aid regions andwas tasked to develop standard monitoring indicators and check-listdistricts in their supervisory activities 4. : It was suggested for the national office to explore various mechanisms for disseminating and sharing reports resulting from activities undertaken in the regions. Suggestions such as written feedbacks or reports were recommended. 3.0: Follow Up Actions on Recommendations As part of efforts to facilitate the early implementation of the recommendations the national programme staffs have undertaken several field visits to ensure the conduct of the under-listed activities in the regions and districts; o Provided guidelines and logistics for mapping up farm-huts, hamlets and fishing communities in remote communities of the Brong Ahafo regiono Supported recruitment and training of CDDs o Commissioned update of register and subsequent follow up and treatment of communities 4.0: CDTI 4.1: Regional Training und Review meetings The national programme staff, as part of the implementation plan for the broaderNeglected Tropical Diseases programme, embarked on series of review and trainings forSupervisors at both regional and district levels throughout the country. The meetings formed thebasis for commencement of activities leading to the successful implementation of the 200g massdrug administration. - The meeting- assembled regional focal persons and supervisors, District Directors ofHealth Services, Public Health Nurses, Disease control officers and Medical Statisticians todeliberate, review previous activities and strategizefor year 2008. other issues discussed include im-portance of updating the community register prior to ih" MDAs, social mobilization strategies, effective communication of IE&C messages; management and referral of severe adverse reactions, etc. were stressed. The meeting also reviewed activities carried out during the previous year and agreed on strategies for integrating and mobilizing increased support for Oncho controlin the regions' The need for effective collaboration with oth.. stakeholders was also stressed. 5 The following staff cateSories were present in the review meetings; District Directors of Healthservices, Public Health Nurses, Disease control officers, Biostatisticians and coordinators. 4.2: Logistics Delivery Allregions received the required quantities of drugs and logistics from the central medical storesfor onward delivery to endemic diitricts in June. 4.3: Community Education and Mobitization Most communities have commenced sensitization activities with the view to ensuring thatIvermectin reach all eligible persons for an improved coverage. The focus of activities has beenon community meetings and durbars to soli.it the full cooperation and participation ofindividuals for a successful treatment campaign. The ,.gion, are also engaged in media briefingsand radio discussion, especially in areas endowid with radio facilities. Traditionalcommunication channels such as gong-gong beating, roof-top announcements, etc. are also beingemployed. 4.4: Distribution of Drugs to Eligible population All districts, including both SIZ and non-SlZ,have commenced Ivermectin treatment butare at various stages of the distribution process. Monitoring of treatment and severe adverseevents are still on-going. 6 N9t! 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The programme management,sposition is to strategize and focus interventions for the new foci identified while we wait for thefinal report from MDSC, Ouagadougou. 6.0: Key Challenge Implementation of the GDTI activities, like any other programme, continues to facechallenges some of which are listed below; o There is shong competition among programmes at the district level for implementationo Delays in funding oncho-onry areas foi imprementation of activities 7.0: Way Forward o In the ensuing months the Nocp hopes to accomprish the following; complete treatment at both SIZ and non-SIZ u..u, und report continue -advocacy with Ghana Health service authoiities and various stakeholders toadvocate for declaration of ,national NTDs day, Engage Togo NOCP in cross border meeting a a otr E E flt Fo N o N o ooa EcJr Ee o FOdEso -o EB oo@ o @No +6 o 8N @ oN @ o I@ oI oo o @ @ o N o o ) f,oF a N @o @ @ oN @ o ., t e)! I! o oE o ! cd o o o o o I € @E o oc o g od oc I o @ E I Iq);) D c o c o)o I! 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E o E o o! E ot o _c .s oq f oc ! o o o o o n 't o ; o e E o ! oF @ooN ! €o a e d o ! o !! oo oE oq ! C b srE RE h.9 agfo EE EA o: o-d:o 5€ Fd tr .9 E d t E ! o E o o E E E6 o c o oo oE o o :E e E E n o n o o !( o I c o oFl : o FooN ; C o E o oEt g o: o E oF ooo N E .9o o E E o tr c @ lo J FoF o z 26a2 PE =U6* =6 J FoF;f c o roN0 of,t o) oo N F lolo!t o) @ o{ o o I d 5 co c c o o6 Eo l ! c 6 EI c a Eo a ! c oo N c o J o o 't o ,d o c o oC Eo C c o 2 f o i o C q E o o :- EoJ ! c n e nq o o o C o o a =Eof E g dq ee 6 o o oE tro o :ogx (, zFtroe uJ e. J FoF ta)(\ a 6I\ oTo lt o)It .o U, o uo P) E tr5\ B. SIERRA LEONE SUMMARY REPORT OF NOCP/NTDS ACTIVITIES IN 2OO8 The main strategy for onchocerciasis control in Sierra Leone since 2003 is Mass DrugAdministration (MDA) through community Directed Treatment with Ivermectin (GDTI), whichis generally a pro-poor, self help project. MDA for treatment of Onchocerciasis is expected to cover a population of about 2.3 million people living in l2 out of the l3 health districts of Sierra Leone that are endemic for Onchocerciasis. The NOCP was unable to conduct MDA using theCDTI strategy in 2003 and 2004. However, since August 2005, the NOCp has succeeded in conducting 3 rounds of MDA: by May 2006 about 1,300,000 people (s4.g% of the targetedpopulation) were treated; 1,700,000 people were treated by February 2007 (74.3%of the targetedpopulation); and 1,770,000 people were treated by February 200g (75.3% of the targetedpopulation). The NOCP is presently covering 8,451 villages in all the l2 provincial districts ofSierra Leone that are endemic for onchocerciasis and use 16,902 CDDs for Ivermectindistribution (an average of 2 in each village). According to the onchocerciasis Control Programme (ocP) onchosim simulations, it is necessary to have a therapeutic coverage of at least65Yo and a geographical coverage of 100% over a period of l4 years and above in orderto break transmission of Onchocerciasis. This target was achiev ed in 2007 treatment (which ended in February 2008) and should be maintained for the next l3 years. A review of 2007 NOCP activities was conducted in April 2008. Representatives of all the 12 oncho-endemic districts made a power point presentation on activities conducted in 2007 and early 2008, results of mass distribution of Ivermectin, problems encountered and possible solutions to these problems. 2,352,586 people were targeted for treatment and 1,770,757 were treated with Ivermectin, giving a therapeutic coverage of 75.3%o. All 8,451 villages targeted for treatment were covered for the first time in 3 years, giving a geographic coverage of 100%. 5,183,488 tablets of Ivermectin were used to treat the 1,770,757 people and 1,090 cases of mild drug reactions were reported in the l2 districts. constraints reported during the review included the following: o Presence of some hard to reach areas, especially the river areas;o Some cDDs still have problems preparing the yearly report forms;o some cDDs are demanding incentives for the service tliey render. Recommendations of the review included CDDs are to be motivated through the provision of certificates, T shirts, flyers, badges etc., and through use of CDDs for the integrated management of NTDs, Malaria and other healthinterventions. 2"ffilfflmotor cycles preferably XL l25s which are appropriate for the bad roads or 3' Intensification of community meetings to reach ail popurations. ! Advocacy meetings *lt!r_l!1n.wry erected city and district rocar councirs5. Continue training for DHMT, pHt staff and CDDs.6. Strengthening of supportive supervision at all levels. After December 2007, the NocP is receiving financial support from the Government ofSierra Leone' the African Programme for onchocerciasis control (Apoc) and Sight SaversIntemational (sSf ' Since 2007, the NocP is also responsible for treatment of neglected tropicaldiseases (NTDs) in Sierra Leone. The NOGPAITD control programme is receiving funding alsofrom Research Triangle Institute (RTD through Helen Keller International (HKI) for integratedtreatment of other NTDs such as Lymphatic Filariasis (LF), soil rransmitted Helminthiasis(srH)' Schistosomiasis and Trachoma with onchocerciasis. Therefore all activities conductedare integrated to cover all onchocerciasis and the other NTDs. The NocP started a new cycle of CDTI activities for the year 200g and between July andoctober 2008 succeeded in compreting the foilowing activities: Refresher training of trainers (TOT); Refresher training of pHU Staff; Community meetings in I I districts; Miscellaneous activities. A refresher ToT on CDTI was organized in 2 sessions by the Nocp in Makeni (07 -09/07108) and Bo (lo - l2/07l08) towns. 4 members of the District Health Management Teams(DHMTs), including the District Medicalofficers (DMosf and the District oncho Focal points,were invited from Kono, Port Loko, Kam_b]a, Koinadugu,'Bombali and ronkolili districts to theTor in Makeni between 7h and 9th July 2008. The ,ui" g.orps of 4 people were invited fromKailahun, Kenema, Bo, Bonthe, Pujehun and Moyamba di"stricts to attend the ToT in Bo Townbetween the lo'h and l2th July ioos. n.presentatives of the onchoA.{rD working groupparticipated in the 2 training sessions. These lncluded representatives from partners such as HKIand SSI, the Eye care, School Health and Health Education programmes of the Ministry ofHealth and Sanitation, 12 NOCPAITD staff, including 8 Entomology Technicians. The Torlasted for 3 days each and the agenda was on operational issues such as problems detected in thedistricts during previous CDTI and how these problems can be avoided in the future. New issuesrelating to integration of onchocerciasis and fF treatment in the districts were discussed. please see agenda (Annex I below) for details of training. The forms used for CDTI were also reviewedto accommodate treatment for LF. The NocP succeeded in completing training of all 800 pHU staff working in areaswhere onchocerciasis is endemic in ihe tz olstricl using funds from the ApoC, SSI, andRTI/HKI 12'h - 22nd July 2008. The agenda used was ideniical to the agenda used at the Tor. l3 The Training of PHU staff in the districts lasted for 3 days each and the agenda was onoperational issues such as problems detected in the Jkui.o during Ivermectin distribution andhow these problems can be avoided in the futur;.- New. issues relating to integration ofonchocerciasis and LF treatment in the districts weie discussed. The fo.r, reviewed toaccommodate treatment for LF at the Tor were utro air.ursed. g00 pHU Staff were trained inthe 12 Districts endemic for onchocerc^ysi1 i, Jriy ,06i. DHMT members that attended theToT conducted the training of PHU staff within ir,Ji. * prctive districts. Members of the Nocpalso attended ail pHU trainings and acted as additionar faciritators. Since GDTI is being established for the first time in Sierra Leone, there is need to enterand hold meetings in each of the villages where CDTI is to be conducted. This is to improve theknowledge of various communities on GDTI and to get them committed to playing the majorrole of distributing Ivermectin once a year, which needs to continue for at least l5 years. TheNocP conducted community meetings in 7,645 villages of I I districts between z3,d July 2oogand 6n August 200g. Many problems were detected during the last CDTI cycle relating to communities, suchas the following: -High refusal rate due to "wait and see attitude" due to the side effects that have occurred insome communities; -cDDs are now demanding some form of incentives. The promise by communities to providesome form of incentive was not fulfilled. District health workers conducted the community meetings in the villages and thesecommunity meetings were supervised and monitored by members of the respective DHMTs,Representatives of Supporting Agencies such as Helen Keller International (HKI) and SSI, andStaff of the NocP' District health workers had to address these problems during communitymeetings and ensure that cDDs are reselected in communities were previously selected cDDshad refused to distribute Ivermectin during the last MDA. Salaries were paid to non-ministry of health workers who are attached to the Nocp forthe months of January, February, March, April and May 2008. Lump sums were also paid to theProgramme Manager and some other members of the Nocp for the period January-May 200g.Repairs and maintenance were conducted on the 4 oNCHo/sruvehicles remaining with theNOCP. 14 PLAN OF ACTIONS AND BUDGET Executive summar? Studies conducted this year and in the immediate past have shown that Sierra Leone isendemic for all the 5 frontline Neglected Tropical Diseases (onchocerciasis, LF,Schistosomiasis, STH and Trachoma). However, mass ireatment will be needed for only 4 ofthese 5 (Trachoma will not require mass treatment). All l2 provincial Districts of sierra Leoneare endemic for onchocerciasis with prevalence of 4}Yoand above and are to be treated using theCDTI approach' The western Area and the riverrine areas of Bonthe Districts are hypo endemicfor onchocerciasis and are not to be treated for onchocerciasis. The survey conducted on LF in 2005 showed that all the I3 districts, including westernarea' were found to be positive for antigenaemia of w. bancrofti. overall uriig"nu"ria rate forthe country was found to be 23.3% out of 1982 individuals examined from 34 locations.According to wHo guidelines, a district should be covered fully (all villages treated) if the LFprevalence is I% and above. Studies conducted in 2008 to determine prevalence of Schistosomiasis and STH in all I3districts have indicated that 4 districts (Kono, Koinadugu, Kenema and ronkolili) definitely should receive mass treatment for Schistosomiasis Manslni. A 5s district (Kailahun) had lessthan 50%:o prevalence required for mass treatment but hospital records have shown thatSchistosomiasis is a problem in the district. The Nocp is therefore planning to treat forSchistosomiasis in this district also. Prevalence for srH was generally low in all districts, exceptfor Hook worm' According to wHo guidelines, Hook worm prevalence between 20%o and 30o/o requires mass treatment. since mass deworming has been going on in schools, this should be encouraged to continue but treatment should be coordinated to avoid duplication. The Trachoma survey revealed that prevalence of the disease in the 5 districts is below 1%o' The prerequisite for mass treatment is that prevalence of the disease among children l-9years should be 1 joh and above. Therefore, no mass treatment will be conducted for trachoma.Health workers will be trained on how to diagnose Trachoma and treat the few who will sufferfrom the disease. The NOCP has identified 2 key priority areas: o Management of onchocerciasis, LF and STH through (A) annual MDA and (B) morbidity control; o Management of Schistosomiasis and STH through (A) annual MDA in schools of 5Schistosomiasis endemic districts. Subsequently 3 priority objectives were set: l ' To Distribute Ivermectin and Albendazole tablets to at least 65yo of taryet population andtreat l00Yo of villages targeted;2' To establish a system of helping people with LF related conditions (hydrocoele, lymph ^ oedema, lymphangitis) in all llendemic dishicts;3' To.establish a system of treating school children annually for Schistosomiasis and STH in the5 districts endemic for Schistosomiasis. Objective I has the following targets: l ' Improve knowledge on NTDs in all targeted communities through advocacy meetings, - community meetings and production of IEC materials;2' Trainings to improve skilli of health workers and volunteers to manage programme at pHUand community level through a training of trainers (Tor), training or"puu Iiaffand trainingof community volunteers;3' conduct mass drug administration (MDA) of Ivermectin and Albendazole in all targetedcommunities; 4' verify reported coverage in all districts through a coverage survey (zlogsurvey will be for2008 treatment); 5. Cover administrative costs. Objective 2 has the following target: I 'To create opportunities for people with chronic conditions relating to Oncho and LF to betreated through provision of special footwear, medical kits for p.opl with lymph oedema andprovide for free surgery for people with hydrocoele. Objective 3 has the following targets: I 'To Distribute Praziquantel and Albendazole tablets to at least 85% of primary school children and treat 100% of Primary schools in the 5 targeted districts. This will be donsthrough advocacymeetings, meetings in all schools, provision oilpc materials, TOT, Training of pHu staff,Training of teachers; Distribution of drugs and other logisticsto schools, Monitoring andsupervision of MDA. 2.To provide for administrative needs of the School Health programme. t6 Summary Budget PRIORITY AREA OBJECTIVES TARGETS TOTAL cosT LE Funding sourcc Improve on rn all targcted communrti. HKI, voluntecrs to managc programme at pHU and communtty level trainings to improve skills and SSI ofspecral materrals nceded for drug d 28,460,000 HKI, APOC of Ivermcctin andConduct mass drug admrnistration Albcndazole rn all targcted communltics HKI, APOC, SSI Ven! reported coverage in all drstrrcts 5,000 HKI Drstflbute Ivermectrn and Albendazolc tablcts to at least 650Z of targct population and Eeat 100% ofvrllagcs targetcd Admln tstratlve costs r 50,000,000 GOSL, HKI, APOC Provtde footwearspectal for wrthpeopl oedema 00Lymph per drstrrct x 3 d rstncts) ( r00 per drstflctProvtde free surgery for destrtute wrth x I 3 drstrrcts) 32s,000,000 GAP ( I ) Manage Onchocercra sis, LF and STH through (A)annual MDA and (B)morbidrty control Establrsh a system of helprng people with LF related condrtrons (hydrocoele, lymph oedema, lymphangttrs) rn all l3 endemrc drstncts eProvrd, krtmedrcal for wlthpeople oedema 00Lymph per xdrstnct 3 drstrrcts) 26,000,000 GAP treattng school chrldren annually for Schrstosornrasrs and STH rn the 5 dtstncts endemrc lbr Sch lstosom rasrs Establsh a system of prrmary school chrldren and treat lO0%o ofprrmary schools tn the 5 targeted dtstflcts Prazrquantel and Albendazo le tablets to at least 85% 992,399,000 GAP (2) Manage Schrstosomra srs and STH through (A)annual MDA rn schools of 5 Schrstosomra srs endemrc drstncts Provrde for admrnistratr ve needs ofthe School Health Programme 65,500,000 CAP TOTAL LE 4,320,927,000 l7