Country-specific onchocerciasis control issues: Benin, Burkina Faso, Côte d'Ivoire, Ghana, Guinea, Guinea-Bissau, Mali, Niger, Sénégal, Sierra Leone, Togo

tt 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 EXPERT ADVISORY COMMITTEE Twenty-third Session Ouasadoueou. 23 - 27 September 2002 EAC23.7 COUNTRY-SPECIFIC ONCHOCERCIASIS CONTROL ISSUES BENIN BURKINA FASO COTE D'IVOIRE GHANA GUINEA GUINEA-BISSAU MALI NIGER SENEGAL SIERRA LEONE TOGO \ F! ONCHOCERCIASIS CONTROL IN BENIN Achievements and Prospects after OCP ,I INTRODUCTION 1.1 Onchocerciasis in West Africa before OCP ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. ' It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northem parts of Benin, Togo, COte d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers | 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. I r I An agreement signed in 1973 between the participating governments and wHo defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Governments" in January 1974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidarity, 22 countries and institutions financed the activities of OCP for nearly three decades. 2 tr 1.2. Control Strateeies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. I 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II ONCHOCERCIASIS IN BENIN 2.1 Onchocerciasis in Benin before OCP . Benin is one of the first seven countries of the Programme. . Before the launching of control activities, the country was a highly onchocerciasis endemic zone, especially in its northern part with prevalence varying from 25.5%o to 84.2% and the Community Microfilarial Load (CMFL) varying between 2.27 and 36.83 MF by biopsy. . Annual Potential Transmission (APT) was between 0 and 1,398 while the Annual Biting Rate (ABR) was between 8 and 29,205. UI. CONTROL STRATEGIES USED 3.1. Vector Control . It is based on rotational insecticide larviciding. . Control began in 1977 (phase III of OCP operations) and covered the basins north of the country, namely, Alibori, Sota, M6krou and Pendjari. . In February 1988 it was extended towards the south on the basins of the Ou6m6, the Okpara, the Zou and the Mono. r J ,\ 3.2. IvermectinTreatment ' Ivermectin was introduced in 1988 in the basins of Benin (K6ran, Perma, Yerpao, Kara, Ou6m6, Okpara, Zou, Kouffo and Mono). . From 1988 to 1997 treatment was done by mobiles teams (health workers). ' Since 1998 treatment is done by the communities themselves and has involved more than 2800 endemic villages. 3.3. Training To ensure the maintenance of the achievements of the Programme by the Participating Countries, OCP undertook the academic and on-the-job training of the nationals particularly in control strategies. 3.4. Other stratesies Information, Education and Communication (IEC), epidemiological and entomological surveillance also constitute strategies for the control of the disease. IV. RESULTS IN 2OO2 4.1. On the epidemioloeical level The results are very satisfactory in all the basins. In2002 out of 60 villages evaluated 52 (87 %) had prevalences of between 0 and 5 % (objective < to 5 %). The prevalence passed from 59 to 1,1 oZ on the Niger and its tributaries, from 70 to ll o/o on the Okpara, 72,4 to 1,8 o/o on the Zou. On the Mono and the Ou6m6 in spite of prevalences of around 20 to 30 % in certain villages one notes a tendency of regression. The Community Microfilarial Loads (CMFL) are quasi nil everywhere (standard < 1). 4.2. On the entomolosical level The Annual Transmission Potential (ATP) passed from 2313 to 107 at the Alibori capturing point in Alibori, from712 to 57 in K6r6mou in M6krou and from 538 to 0 in F6r6kire in Sota. (objective < 100). Some minor pockets of transmission persist: M'B6t6koukou on the Ou6m6 where the Annual Transmission Potential passed from 5206 to 867 between 1988 and 2001 and of Atch6rigb6 where it passed from 6147 to 72 during the same period. 4.3. Ivermectin Treatment (CDTI) The objective is to treat 100% of the villages and at least 65Yo of the population of each eligible village. In 2001, the geographic coverage was 81,3o/o (2594 villages treated out of 3194) and the therapeutic coverage 77,7oh (l 017 867 people treated out of 1 310 661 listed). It should be noted that the coverage rates are improving year by year. 4 4.4. In the field of training On the whole 60 people in Benin underwent training through OCP sponsorship, namely, 12 in entomology, 13 in public health, 12 in ophthalmology, 12 in management of the health services, 04 in epidemiology, 04 in parasitology and 03 in hydrobiology. The doctors, nurses just as the Community distributors of the endemic zones were trained in onchocerciasis control strategies. V OBSERVATIONS Strengths Significant reduction in the prevalence, the incidence, the CMFL, the number of blind and finally of the annual transmission potential. National executives trained in various fields: public health, epidemiology, entomology, management etc... Obvious political commitment and a clear implication of the communities in the control of onchocerciasis. The future Multidisease Surveillance Centre (MDSC) in Ouagadougou could be an operational structure of concertation among the Participating Countries after 2002. Weaknesses Persistence of some capturing points in the Ou6m6 basin presenting completely unsatisfactory results. CDTI Geographic coverage remains lower than the objective set in certain villages and health centres. Insufficient financing and materials for the decentralised structures, for the implementation and follow-up of activities, particularly for health centres of the sub-prefectures. vI. CONDITIONS TO SUSTAIN AND IMPROVE ACHIEVEMENTS To have an effective supply system of the needed quantities of ivermectin (given freely by MDP) for the endemic villages To treat 100% of the endemic villages regularly and at least 65% of the population in each village by continuing the CDTI reinforcement actions already undertaken and also by the implementation of the stringent measures. Making available to the decentralised structures financial and material means sufficient for their activities. Regular monitoring of the activities, continuation and intensification of the sensitisation of the populations in order to guarantee their best involvement. Epidemiological and entomological surveillance aimed at monitoring the evolution of trends and to detect a possible recrudescence of the disease. With this intention, the national prograrnme of onchocerciasis control in Benin must have the trained personnel as well as the adequate material and financial means. 5 ,, ONCHOCERCIASIS CONTROL IN BURIflNA FASO Achievements and Prospects after OCP ,L INTRODUCTION 'hocerciasis in ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. . It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northem parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers t 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. r An agreement signed in 1973 between the participating governments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Govemments" in January L974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidarity, 22 countries and institutions financed the activities of OCP for nearly three decades. 2 1.1 n n 1.2. Control Stratesies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. il. ONCHOCERCIASIS IN BURKINA FASO BEFORE OCP Burkina Faso is one of the first seven countries of the Programme and the country where vector control operations first started due to its high endemicity. The onchocercal hyper-endemicity was observed on the river courses. Prevalence reached 83% with CMFL varying between 1 and 25 microfilariae by biopsy. The rate of blindness was about l0%. The Arurual Transmission Potential (ATP) varied from 0 to 1.263, whereas the Annual Biting Rate (ABR) varied between 0 and 26.314. The fertile lands of the basins were deserted by the farmers with a consequent fall in productivity and production. The brave farmers having become blind and a social burden were reduced to begging and led with the aid of sticks in Indian file. a a III STRATEGIES 3.1. Vector control It is based on insecticide rotational larviciding It began in 1975 in the western part of the country. In 1977 all the basins of the country were put under aerial larviciding. Vector control stopped in 1990 on all the basins due to the good results recorded. The resumption of ground larviciding in 1990 on the Dienkoa followed upon the detection of a residual transmission. 3 I a a a a I I t3.2. Ivermectintreatment The ivermectin treatment began in 1990 on the Dienkoa basin following the detection from a residual transmission The ivermectin treatment was also instituted in 1996 on the Bougouriba following a resumption of transmission. Carried out initially by the mobile teams (by health workers), then community based, it is currently carried out by the communities themselves since 1998 through the "Community Directed Treatment with Ivermectin" (CDTI) in more than 300 endemic villages. 3.3. Trainins of nationals To ensure the sustainability of the achievements of control activities by the Participating Countries, OCP undertook the academic and on-the-spot training of nationals particularly in control strategies. 3.4. Other stratesies Information, Education and Communication (IEC), epidemiological and entomological surveillance also constitute strategies for the control of the disease. IV RESULTS IN 2OO2 On the epidemioloeical level Prevalences are lower than 5%o on all the basins against more than 80o/o at the beginning of the Programme (objective < 5Yo). Incidences are almost nil. The Microfilarial load in the communities is almost nil. On the entomological level The Annual Transmission Potential (ATP) is lower than 100 (objective < 100) on the basins implying an intemrption of the transmission of the disease. Ivermectin Treatment The objective is to treat 100 % of the endemic villages and at least 65 % of the population of each village. 1n2002,100% (346 out of 346) villages were treated and 120,468 people out of 172,342 listed (i.e 70 o/o) received treatment. In the field of training On the whole 90 people underwent training in Burkina Faso under OCP sponsorship, mainly, 18 in entomology, 18 in parasitology, 16 in public health, 13 in management of the health services, 07 in ophthalmology, 08 in epidemiology, 07 in administration and 03 in hydrobiology. 4 a a \V OBSERVATIONS Strengths Tlle objective for the control is achieved. One notes a significant reduction in the indicators (prevalence, incidence, CMFL, ATP and the number of blindness). Political good will for the integration of onchocerciasis control in the health system of the country. Training of a critical mass of nationals for the maintenance of the achievements and availability of material for diagnosis, data analysis and rounds. Creation of the Multidisease Surveillance Centre (MDSC) in Ouagadougou which could be used as an operational structure for concertation arnong the Participating Countries after OCP. Weaknesses Integration of insufficient activities into the health structures. Concern of a fall in financing because of the success in control Insu ffic i ency o f the travelling materi aUvehi cles. VI. CONDITIONS TO SUSTAIN AND IMPROVE ACHIEVEMENTS Continue the CDTI to ensure 100% geographic coverage and at least 650/o therapeutic coverage in each treated village. Annual epidemiological monitoring of the sentinel villages in all river basins of the country Entomological monitoring for: - the early detection of recrudescence - impact of ivermectin on transmission - studies of post treatment (2002 and 2003) on the Dienkoa. The mobilisation of financial resources by: - the State within the framework of the financing of the National Plan for Health Development. - WHO (Afropoc): ex: $60 000 for 2002-2003 - the NGDOs - the collectivity and communities. 5 a ONCHOCERCIASIS CONTROL IN COTE D'IVOIRE Achievements and Prospects after OCP , ,I. INTRODUCTION 1.1. Onchocerciasis in West Africa before OCP ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. ' It was estimated that in the world: Approximately I22,9 million people are exposed to onchocerciasis. More than L7,7 million people were infected with the disease. More than270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of COte d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers | 235 000 km2 with alrnost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult wonn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating govemments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. I I I After approval of the mission report of the "Support Programme to Govemments" in January 1974, the budget necessary for the implementation of the onchocerciasis control prograrnme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of intemational solidaity, 22 countries and institutions financed the activities of OCP for nearly three decades. 2 n D I.2. Control Stratesies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana" the Mafou and the Tinkisso in Guinea. U ONCHOCERCIASIS IN THE REPUBLIC OF COTE D'IVOIRE BEFORE OCP The initial limits of the Onchocerciasis Control Programme in C0te d'Ivoire, included the most significant foci of savannah Onchocerciasis, as they were known in 1975. These foci included: - The north-eastern part of the country (Bouna- Bondoukou) on the Black Volta - The Upper Comoe, from the border of Burkina Faso to Groumania (Serebou) and the areas of Nassian, Dabakala and Prikro - The Upper Bagoe in the Department of Boundiali - The Upper Baoule in the Department of Odienne. The prevalence rates in these original areas sometimes exceeded 75o/o, the Community Microfilarial Load varied between 15 and 43,per biopsy, whereas the rate of blindness reached t0%. The Annual Transmission Potential (ATP) ranged between 0 and 2 2Il and the Annual Biting Rate (ABR) varied between 0 and 62 596 per man. Following the invasion of the south of the country by infective blackflies, the progralnme area was extended to this part in 1979 (southern extension), especially the hyper-endemic zones in the basins of the Sassandra, the N'Zi-Bandama, Black Volta, Bou-Bandama and the Comoe. a 3 I ,A REMO study carried out in the forest zone in 1998, and which showed an average rate of nodule carriers of about 20o/o, extended the prograrnme to the districts of Alepe, Aboisso, Danane, Soubre, Tabou and Sassandra. III CONTROL STRATEGIES 3.1. Vector control It is based on the insecticide rotational aerial larviciding The operations of aerial larviciding began in February 1975 (Phase I of OCP) in the basins of the N'Zi, the Comoe and the white Bandama. They then extended to the south of the country in 1979, on the basins of the Sassandra, the N'Zi-Bandama, the Black Volta, the Bou- Bandama and the Comoe. 3.2 Ivermectin treatment It is the second control strategy used by the Programme. Ivermectin was introduced in Cote d'Ivoire for mass treatment in 1988. At the beginning, distribution was carried out by mobile teams, made up of health workers of the country and the personnel of OCP. Since 1997 distribution is done in more than 1700 villages, by the communities themselves, through village volunteers. 3.3. Training To ensure the maintenance of control gains by participating countries, OCP undertook the training of nationals, both at the academic level and on the job, especially on control strategies. 3.4. Other strateeies Information, Education and Communication (IEC), epidemiological and entomological monitoring also constitute strategies of control of the disease. 4 \OBJECTIVE OF THE PROCRAMME RESULTS OBTAINED REMARKS reduce the prevalence to less than 5oZ. AREA BEFORECONTROL CURRENT RESULTS Area where no control activity is undertakenORIGINAL AREA Rate of prevalence higher than 60% Average blindness rate 4,8%o The overall prevalence rate lies between 0 and 5% although the evaluations carried out in 2000 and 2001 showed a suspicions trend on the Upper N'Zi in the villages of NAMAYEREDOUGOU (6,7%)and KOBADARA (9,2%) and on white Bandama in2002 at NAGOTINGOKAHA (8,88%). SOUTHERN EXTENSION AREA Prevalence rate ranging between 20 and30Yo The prevalence rate is between 5Yoandl5%o Area under CDTI since 1994 FOREST ZONE Prevalence ranging between 30 and 65% (REMO r998) Area under CDTI since 2002 Iv. RESULTS tN COTE D'IVOIRE IN 2OO2 On the epidemiological level On the entomological level N.B : ATP : Annual Transmission Potential Rate of infectivity: percentage of infective blackflies for 1000 captured females. 5 OBJECTIVE OF THE PROGRAMME AREA RESULTS OBTAINED REMARKS Reduce the incidence to 0%. BEFORE CONTROL CURRENT RESULTS Area where no control activity is undertakenORIGINAL AREA Reduction of99%o SOUTH EXTENSION AREA Reduction of more than 90% Area under CDTI since1994 FOREST ZONE Prevalence ranging between 30 and 65% (REMO l9e8) Area under CDTI since 2002 INDICATOR RESULTS REMARKS ATP BEFORE CONTROL CURRENT RESULTS Between 1000 and 2500 in the original area Lower than 100 On all the points RATE OF INFECTIVITY Original area: 0 at BADIKAHA on the White Bandama South Extension area :Between 0,0623 at AMOUAKOUKRO on the Comoe and 0,1575 at ASSEREKRO on the Kan/N' Zi 2000 data aOn treatment with ivermectin Due to the late delivery of Ivermectin by MDP (September 2001), treatment could not take place in 2001 . For2OO2, all the Districts in the extension area, as well as those of the forest zone were provided with Ivermectin and the treatment is ongoing. The partial results that the Management of the Programme received are encouraging in the Southem extension: * tlre therapeutic coverage rates vary from 60 to 72oh * the geographical coverage rates vary from 60 to 100%' - On training On the whole, 34 Ivorian nationals benefited from a training scholarship, particularly in entomology (24), hydrobiology (4), epidemiology (3), ophthalmology (2), management of health services (1). The doctors and nurses were trained on control strategies, and the village volunteers on CDTI. V OBSERVATIONS Streneths Existence of a constituted multidisciplinary team of entomologists, epidemiologists and technician specialists. 100% of the endemic medical districts are covered by CDTI The doctors of the endemic districts, the nurses and the Community Health Workers (CHWs) were trained on onchocerciasis control strategies. The development and the provision of sensitization material for Doctors, nurses, CHWs and the Communities are effective in the forest zone. Existence at the headquarters of the Programme of a team for evaluation and data management of epidemiological surveillance. Existence of an inspection channel on each basin. Existence in the villages of entomological follow-up of trained village catchers. Weaknesses Irregular official budgetary executions. Insufficiency of logistics (vehicles, fuel and lubricants) or Irregular supervision and follow-up for lack of financial means and logistics. Integration of the former Ivorian technician entomologists of OCP in the national team not yet effective. Low level of involvement of the Districts and health centres in the process of entomological surveillance. The despatching of catching equipment to the DNA laboratory in Ouagadougou is not yet autonomous. Detay in the collection, the compilation and the transmission of data. Absence of incentives for the CHWs 6 , \VI Staff training not completed in the 12 Districts of the forest zone. The decentralization of epidemiological surveillance not yet effective in the districts. Frequent transfers of the already trained health workers. Data on onchocerciasis epidemiological surveillance not integrated in the national health information system. Cu.ry out an annual treatment of all the eligible villages in all the basins, except those of the Comoe and the N'Zi-Bandama, where treatment is biannual Cover 100% of the eligible villages and hamlets with CDTI. Obtain at least 65Yo of therapeutic coverage per village, district and basin Recycle nurses every 2 years and CHWs at least every other year. Carry out regular activities of follow-up and supervision in the Districts (by the central level), health centres (by the district level) and Community (by the health centres). Seek ways and means of motivating health workers and the Community distributors to ensure the sustainability of the system. Make ivermectin available in all the villages * Epidemiological surveillance Gradually decentralize epidemiological surveillance in the districts. Equip the districts in epidemiological surveillance equipment (Holtz grips, magnifying glasses, ringed blades, DEC patch test, etc...) and in fuel needed for the follow-up and the supervision of activities. * Entomological surveillance Identify a reliable channel for sending samples from the Community level to the DNA laboratory, through the health centre, the District and the Headquarters of the Programme. * Data Management Carry out the district staff training on the cross analysis of epidemiological surveillance data.. Set up a continuous feedback system for the benefit of the main actors involved in control activities. * Mobilization of financial resources Maintain and widen the financing of activities by the Ministry of Public health. Carry out advocacy with NGOs so that they may support the activities of control of Onchocerciasis, in particular CDTI in the long-term. CONDITIONS TO SUSTAIN AND IMPROVE CDTI GAINS 7 tI * Availability of human and material resources Reinforce the staff of the programme management by recruiting on its budget, a mechanic, 3 drivers, 1 technician/entomologist. Ensure the maintenance of computer hardware and acquire new materials. 8 IONCHOCERCIASIS CONTROL IN GHANA Achievements and Prospects after OCP , 21.1 I. INTRODUCTION in West Africa before . Onchocerciasis prevails in Africa, America and in the Arabian peninsula. ' It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerclasls. More than 17,7 million people were infected with the disease. More than270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northem parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of COte d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers 1 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating governments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "Support Programme to Govemments" in January 1974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidanty,22 countries and institutions financed the activities of OCP for nearly three decades. I D D - 31.2. esnEol Strategies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children bom since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. 1I. ONCHOCERCIASIS IN THE REPUBLIC OF GHANA BEFORE OCP Ghana is one of seven first countries of OCP to start onchocerciasis control. Onchocerciasis was endemic in all parts of the country; Northern, Upper East, Upper West, Volta, the Southem districts of Brong Ahafo and Ashanti Region and the coastal areas. Blindness rate was up to 3.8 o/o in certain areas . The prevalence was very high: 54 to 84 % and the Community Microfilarial Load was between 10 and 25 microfilaria per snip. The Annual Biting Rate (ABR) was high,29790 and the Annual Transmission Potential (ATP) was between 0 and 1637. Control activities were formerly limited to the endemic areas of the northern half of the country i.e. Northem, Upper East, Upper West and parts of the Brong Ahafo Region. The control activities have been periodically extended to include the northem fringes of the forest zone that is southem parts of the Brong Ahafo, Ashanti and coastal areas of the Volta Region where the non-blinding type of the disease exists with associated psychosocial and economic losses. I D n I 4M. STRATEGIES 3.1. Vector control The main strategy was concentrated on larviciding to eliminate the fly at the larval stage of its life cycle. The aerial larviciding started in 1976 in the northern part of the country on theVolta basin and its tributaries Kulpawn, Mole and Daka. In 1988 it was extended to southern part on the Pru river. 3.2. Ivermectintreatment In 1987 ivermectin was introduced into the Programme as a microfilaricide. This is now the main thrust of the control activities, aerial larviciding having been stopped in most of the river basins as a result of satisfactory results. At the beginning the drug was distributed by health teams through mobile means. Today this activity is carried out by the communities themselves through Community distributors in more than 2800 villages. 3.3. The trainine of nationals To ensure the sustainability of the achievements by the Participating Countries, OCP undertook training of the nationals at the academic level as well as on-the-job trainings. 3.4. Other strateqies Information, Education and Communication (IEC), epidemiological and entomological surveillance are also other strategies used for oncho control. ry. RESULTS IN 2OO2 4.1 Sienificant results in Ghana Land has been recovered for agricultural activities and socio-economic development. Children under 20 years are not at risk of the disease. Epidemiolo eical results The prevalence rates have dropped to less than 5 o% in several basins. For example the prevalence dropped from72.6 to 4 o/o in some areas on the rvhite Volta basin, from 68.8 to 8.4 o/o on the Black Volta basin. The CMFL is lower than 1 microfilariae/snip in several river basins. There are some areas which continue to have prevalence rates above 30 Yo inspite of vigorous control efforts. These are the trouble areas which need special surveillance. Entomolosical results The ATP rate is 0 in several basins except in the Pru basin where it is around 140 (the objective is < 100). The ABR rate has dropped and is less than 700. 5CDTI results Therapeutic and geographical coverage targeted at 65+ and 100% respectively are not being achieved. The therapeutic coverage for 2000 has dropped from 63.8% to 50.5%. - Trainine results A total of 4l people in Ghana have benefited from OCP fellowship, 10 in entomology,14 in epidemiology, 4 in parasitology, 4 in hydrobiology, 2 in ophthalmology, 2 in management, 4 in administration and 1 in public health. The doctors and the nurses of the endemic zones have been trained on the oncho control strategies as the Community distributors on the CDTI implementation. V. OBSERVATIONS CDTI Drug is ordered directly from MDP with assistance of UNICEF/Ghana. Though there is a good drug Supply System in place, there are problems of communication and administration difficulties which delay the distribution at the community level. A workshop on ivermectin management has been organised for Regional Pharmacists and Medical Store personnel. Regional Pharmacists are:- in-charge with collaboration of the chief pharmacist. Retums and data analysis Returns have been very slow with long delays in submission Epidemiolo eical S urveillance Regional teams are in place to carry out this activity but it is expensive. IEC Implemented at regional level National level collaborates TV emissions Entomoloey Trained entomologists, technicians and other auxiliary have been identified to carry out surveillance activities a VL CONDITIONS TO SUSTAIN AND IMPROVE ACHIEVEMENTS CDTI - to achieve 10! % eeosraphical and at least 65 oZ therapeutic coveraqe Retraining of CDDs Provide incentives to Health staff at Sub-district level Provide motivation in kind to CDDS Increase period of holding of drugs by CDDS Annual National Meeting on CDTI after treatment period Strengthen monitoring at sub district level. Epidemiolo eical Surveillance - Facilitate release of Regional team. - IEC in areas where prevalence is 0%. - Financial Support from National level to the regions a 6Entomolo eical Surveillance - Entomological surveillance in the Pru river basin to evaluate the efficacy of larviciding will continue. There is therefore the need to maintain the entomological team at Kintampo. - Entomological surveillance will have to be conducted in the eastern part of the Volta Lake, specifically, at Dodi Papase on river Asukawkaw and at Wegbe on river Dayi, (where larviciding have just ceased) to justify the cessation of larviciding. - Entomological surveillance will also be mounted in an area in Northern Ghana which is on ivermectin distribution (area yet to be selected) to determine the impact of the distribution of the drug on the transmission. - There is therefore the need to have enough funds to enable these activities to go through. Data manaqement - Retraining of sub-district staff at District level - Maintenance of computer. Mobilization of required financial resources Budget line for oncho control Hold partner's meeting Availability of human resources a ONCHOCERCIASIS CONTROL IN GUINEA Achievements and Prospects after OCP II. Ir ? 1.1. Onclroc. Africa be Onchocercia:; ,;revails in Africa, America and in the Arabian peninsula. It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than 270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, C0te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers 1 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult wonn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating governments and WHo defined the limits, the objectives, the of consultative structures and management of the Programme as rvell as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Governments" in January 1974, the budget necessary for the implementation of the onchocerciasis control prograrnme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidaity, 22 countries and institutions financed the activities of OCP for nearly three decades. I 2 a 1.2. Control Strateeies used The rnain strategy used is vector control to which ivermectin tre. In certain areas, vector control was the method used and in others iverr, some others on the other hand, the two strategies were combined. { )a9% 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. r Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about l7 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II. ONCHOCERCIASIS IN THE REPUBLIC OF GUINEA BEFORE OCP The republic of Guinea is considered as the water reservoir of West Africa, and is also a vast onchocerciasis territory. The disease covers about 218,000 sq km (about 85% of the total area. At the outset of control, more than 2 million Guineans were directly exposed to the disease, with 560,000 of them being carriers of microfilariae and 20,000 blind. The prevalence of the disease was over 80% in some villages, and the Community Microfilarial Load was 45o/o, with a blindness rate of about 10%. The Annual Transmission Potential (ATP) was between 0 and 2075, while the Annual Biting Rate/man (ABR) varied between 1290 and25,767. III. CONTROL STRATEGIES The Onchocerciasis Control Programme is based on two main strategies: vector control (larviciding, used in rotation on watercourses), which was, and remains the main onchocerciasis control strategy. The programme had a second control strategy, when ivermectin (microfilaricide) came on board in 1987. J In Guinea, the combination of the two strategies (vector control and treatment with ivennectin) on the field actually started in 1989. The evaluation of vector control started by the establishment of an administrative and Eeclinical structure, made up of sectors and operational bases, charged with entomological surveillance in I I river basins. Beginning 1991, two sectors: Kankan and Faranah supervised the entomological evaluation activities of nine operational bases in eight river basins. Upon the cessation of larviciding in the basins of the upper Sassandra, Sankarani, Milo, Mongo Kaba and the Kolente, the operational bases of Beyla, Kerouane and Mamou were closed in December 2001. Currently, larviciding is carried out only on the basins of the Niandan, Upper Niger, Mafou and the Tinkisso. Treatment of the populations with ivermectin actually started beginning 1989, with mobile OCP/national teams. Treatment is now carried out by the communities themselves, through the Community-Directed Treatment with Ivermectin (CDTI) approach, thanks to village volunteers called community distributors (CDs). To ensure the maintenance of control gains by the Participating Countries, OCP undertook the training of nationals, as well in the academic domain, as onthe-job, especially in control strategies. Information, Education and Communication (IEC), the epidemiological and entomological rnonitoring also constitute strategies for control of the disease NGO support, such as that of OPC and SSI are critical for the post-OCP period IV. RESULTS IN 2OO2 Entomoloeical level The main indicator is the Annual Transmission Potential (ATP). As of 31 December 2001, this potential varied over the entire basins between, 0 and 56 infecting larvae/man/year, whereas the standard should be lower than 100. Epidemioloeical level The onchocerciasis prevalence, which was between 43Yo and 8802, prior to treatment, is now reduced to 10o/o, and even OYo in some cases, due to the combined strategy of vector control and ivermectin treatment. 4 Ivermectin treatment In2002,7320 villages were treated out of the planned 7478 (98% of geographical coverage), and out of 2,455,457 persons registered, 1,989,850 were treated(81% of therapeutic coverage) These results are relatively good, given the fact that the main CDTI objective is to have IO0% geographical coverage, and at least 65Yo of therapeutic coverage. Trainins On the whole, 350 doctors, nurses and heads of health centres, as well as 14,453 community distributors were trained in OCP control strategies. Besides, 16 prefecture epidemiological surveillance teams were identified and trained in the prefecture health directorates. Eighty-five Guineans benefited from OCP training scholarships, of which forty-one were in entomology, nine in epidemiology, five in parasitology, ten in hydrobiology, five in public health, three in ophthalmology, nine in health service management, etc. V. OBSERVATION Strengths Vector control, the basic strategy of onchocerciasis control, has enabled the transmission of the disease to be reduced in a remarkable way in the OCP area. At the present stage of control, the disease is no longer a public health concern, neither is it an obstacle to socio-economic development. There is a national decentralized health system, and a national will to ensure integration. CDTI, which is less onerous, has given rise to quite high geographical and therapeutic coverage rates. There is a qualified national staff on the field to continue control activities. Partnership exists between NGOs such as OPC, Sight Savers International and HKI. Weaknesses The services of community distributors are offered free of charge; this compromises the sustainability of the strategy, with the continuous claim for incentives by the distributors. Low level of involvement of local representatives in the CDTI process. VI. CONDITIONS TO SUSTAIN AND IMPROVE ACHIEVEMENTS AFTER 2OO2 Arrive a|100%o geographical coverage, and at least 65Yo therapeutic coverage in each village under CDTI, at each treatment session. In the southern part of Guinea, undertake a complete census, on a periodic basis, in the refugee camps to ensure management under CDTI. The prefecture epidemiological surveillance teams must have adequate equipment for detecting new onchocerciasis cases among the population. There must be required training for village catchers in entomological monitoring. 5 Continuation of the epidemiological and entomological surveillance. Ground treatment in the areas of socio-economic interest, has proved to be against blackfly nuisance on 12 points. Need to develop advocacy with new donors, for mobilizing needed resources for the maintenance and improvement of gains. Making available to the national onchocerciasis control programme a staff that is already trained on strategies. Need to renew and"/or beef up vehicle fleet, as well as field technical equipment (for skin snip test and catches/dissection) 6 a-.'* 1 f ONCHOCERCIASIS CONTROL TN GUINEA-BISSAU Achievements and Prospects after OCP L INTRODUCTION Onchocerciasis in West Africa before OCP ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. ' It was estimated that in the world: Approximately t22,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than 270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers t 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences ofonchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating governments and wHo defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Governments" in January L974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of intemational solidaity, 22 countries and institutions financed the activities of OCP for nearly three decades. 1.1 2 , I t1.2. Control Strateeies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve'on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases of blindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II ONCHOCERCIASIS IN GUINEA.BISSAU BEFORE OCP In 1958, two very significant points of onchocerciasis were found at the border with the Republic of Senegal, close to Kolda and Kedougou. Other cases were also confirmed on the frontier area with the Republic of Guinea Conakry, on the basin of the Rio Corubal, in the villages of Cabuca and Fulamory. The first cases of onchocerciasis described in Guinea Bissau date back to 1965 in the villages around the town of Sonaco. The Onchocerciasis Control Programme began its activities in Guinea-Bissau inl989. Epidemiological prevalence levels varied from 0 to 73 o/o on the Rio Corubal basin and 0 to 30 %o on the Rio Geba. The Community Microfilarial Load (CMFL) reached 30 on the Rio Corubal, as against 4 microfilaria per biopsy on the Rio Geba. The rates of blindness went from 0 to 3 o/o on the Rio Corubal, and from 0 to 5 o/o on Rio Geba. On the entomological level, the Annual Transmission Potential (ATP) was 36 and the Arurual Biting Rate (ABR) was 1,210. 3 -.,1 n /III. CONTROL STRATEGIES 3.1. Treatment with Ivermectin It is the only control strategy used in the Programme in Guinea Bissau. Ivermectin was introduced for mass treatment in 1990, but distribution was derailed by the social and political disturbances that year. Cur-rently the training of the various actors will make it possible for the distribution of ivennectin to resume (through the Community Directed Treatment with Ivermectin or CDTI). 3.2. Trainine To ensure the maintenance of control gains by the Participating Countries, OCP undertook the training of nationals, as well in the academic domain, as on-the-job, especially in control strategies. 3.3. Other strategies Information, Education and Communication (IEC), epidemiological and entomological monitoring also constitute strategies for the control of the disease Iv. 2OO2 RE,SULTS IN GUINEA.BISSAU 4.L. - On the epidemioloeical level The epidemiological evaluation carried out in June 2001 made it possible to visit 37 villages, that is to say twelve (12) in the Rio Geba area and twenty-five (25) in the Rio Corubal area, and gave the following results: The prevalence rate, the CMFL and the rate of blindness are nil in almost the entire evaluated villages. It should be noted that the rare positive cases were found in villages of the Rio Corubal basin (Gabu area). - On the entomoloeical level From June to September 200I,1120 blackflies were caught. All of them were of the savannah species. The total number of flies with L3 in the head was 41. All the flies with L3 in the head were found in the basin of the Rio Corubal, at the Cabuca catching point. 4 ONCHOCERCIASIS CONTROL IN MALI Achievements and Prospects after OCP I. 1.1 INTRODUCTION Onchocerciasis in West Africa before OCP Onchocerciasis prevails in Africa, America and in the Arabian peninsula. It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than 270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northem parts of Benin, Togo, Cdte d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area covers 1 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating governments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "Support Programme to Governments" in January 1974, the budget necessary for the implementation of the onchocerciasis control prograrnme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of intemational solidaity, 22 countries and institutions financed the activities of OCP for nearly three decades. 1.2. Control Strateqies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the fwo strategies were combined. I I 2 o I \1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In sorne limited foci however, there is the need to improve on the results achieved. I Nearly 40 million people are protected today from onchocerciasis and more than 18 n'rillion children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Oueme in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II. ONCHOCERCIASIS IN MALI BEFORE OCP Onchocercal endemicity prevails in Mali in 5 areas, spanning the original area (Sikasso, Segou, Mopti, Koulikoro on the right bank) and the surface of western extension (left Koulikoro left bank and Kayes) of the OCP Programme. Twenty-five circles are concerned and cover an area of approximately 350,472 km2, where more than 5,000,000 people live. At the beginning of control operations in 1977, the preliminary epidemiological data indicated hyper-endemic foci: prevalence 80% (89,6% at Niako on the Baoule in 1977), Community Microfilarial Load (CMFL) > 10 by skin snip test, Annual Transmission Potential (ATP) > 100, with rates of blindness of l2o/o in the original area, and variable from 3 to 10% in the Western extension. The Annual Transmission Potential (ATP reached 998, whereas the Annual Biting Rate was 29.000 bites per man. III. CONTROL STRATEGIES 3.1. Vector control It is based on the aerial larviciding, used in rotation. The larviciding operations began in March 1977 (Phase III of OCP) on the basins of the Baoule, Kankelaba, Bagoe and the Bani before addressing the Niger in 1989. 3.2. Treatment with ivermectin It is the second control strategy used by the Programme. Ivermectin was introduced in Mali for mass treatment in 1988. On the outset, distribution was carried out by mobile teams made up of health workers. ! 3 I t3.3. Trainine To ensure the maintenance of Oncho control gains, by the Participating Countries, the OCP undertook the training of nationals academically, as well as in-service training particularly on control strategies. 3.4. Other strateeies Information, Education and Communication (IEC), epidemiological and entomological surveillance also constitute strategies for the control of the disease. IV. RESULTS OBTAINED IN MALI On the entomological level Today, the transmission of the disease is almost nil on the entire river basins, which are under control (the Niger and tributaries, Farako, Lotio, Banifing IV, Kankelaba, Baoule, Bafing, Bakoye, Faleme, the Senegal and its tributaries). The risk of reappearance of infection of onchocerciasis has been reduced to the minimum. The Annual Transmission Potential (ATP) is lower than 100 (standard < 100) out of the 5 catching points, regularly monitored on the basin of the Niger and its tributaries. The rate of infectivity is lower than I infectious female for 1000 caught females (standard < 1 per 1000 flies). On the epidemiological level Prevalence rates and the Community Microfilarial Loads (CMFL) are very low - zero in the majority of the evaluated villages. In 2001, out of 88 evaluated villages, 66% had aprevalence of |Yo. Only 8 o/ohad a prevalence higher than 5 Yo. Treatment with Ivermectin In 2001 the geographical and therapeutic coverage rates of the villages under ivermectin were 98,7Yo and 78,6oh respectively. In 2002, out of I 562 144 listed persons, I 246 167 (80%) were treated in? 892 villages, out of the planned 3 508 (82%). Training More than 78 Malians benefited from an OCP scholarship, including 38 in entomology, 12 in epiderniology, 6 in parasitology, 7 in public health, 5 in ophthalmology, 5 in hydrobiology, 3 in administration and2 in management of health services. V. OBSERVATION 5.1. Streneths Very satisfactory epidemiological and entomological results in the entire basins under surveillance. 4 Existence of the national teams trained, and able to carry out the epidemiological and entomolo gical evaluations. Ordering of ivennectin, as an essential drug, by the Ministry of health. The eligible endemic zones are under TIDC. Training and involvement of the socio-medical personnel and communities in the activities of onchocerciasis control. Existence of educational material for the communities. Follow-up of activities through the periodic district quarterly meetings, semi-annual meetings of the regions, and the annual review at the central level. Financing of onchocerciasis control activities, through the plans of operation, which benefrt from substantial support from NGOs (SSI, OPC and HKI) and WHO/AFROPOC. 5.2. Weaknesses Instability of some distributors. Illiteracy of some distributors (support available now for their work). Delay in the routing of results of treatment with ivermectin from the village to the health centres, and from the latter to the regional and central level. Dearth of supervisions from the regions towards the circles, from the latter towards the health centres, and from the latter towards the villages. Refusal of certain communities to undergo skin snip tests (the DEC patch will be practised in future, in lieu and place of the skin snip test). Insufficiency of epidemiological surveillance equipment at the regional level. Decrepitude of logistics at the central level. Insufficiency of national financial resources allocated to the maintenance of gains. vI. CONDITIONS TO SUSTAIN AND IMPROVE OCP ACHIEVEMENTS - Reinforcement of the capacities of the decentralized structures to undertake the evaluation and monitoring for the early detection of any recrudescence through: . equipping (with sufficient material and logistics). . Staff training of health personnel of the various levels concerned . The continuous follow-up/supervision of health personnel and distributors. - Effective integration of ivermectin into the essential drug management structures, particularly at the level of regional depots and the health areas, which are yet to do so. - Reinforcement of the system of collection and analysis of data at the various levels - Development of partnership with organizations and development stakeholders interested in the nuisance control. - Support to the NOCP through the supply of equipment and logistics, to enable it to assist the regions and the circles as part of efforts to maintain and build up the gains of onchocerciasis control in Mali. 5 Ia ONCHOCERCIASIS CONTROL TN NTGER Achievements and Prospects after OCP Ll.l INTRODUCTION Onchocerciasis in West Africa before OCP Onchocerciasis prevails in Africa, America and in the Arabian peninsula. It was estimated that in the world: Approximately L22,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than 270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Senegal and Sierra Leone. Today, the whole of the Programme area, covers | 235 000 km2 with almost 40 million people. Before the begiruring of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating governments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Governments" in January L974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidarity, 22 countries and institutions financed the activities of OCP for nearly three decades. ! 2 D ft n l.?. Control Strategies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results ob in the OCP area Onchocerciasis is now eliminated as problem of public health in all the OCP area. In sorne limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases of blindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that. at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II. ONCHOCERCIASIS IN NIGER BEFORE OCP Before the beginning of vector control activities, onchocerciasis was a public health concern in Niger and a real obstacle to socio-economic development. Prevalence rates were 60 70% in certain villages in the district of Say (Boki, Djangore, Alambare), the rate of blindness was estimated at 5o/o in the valley of Meckrou. The Annual Transmission Potential (ATP) exceeded 300 and the Annual Biting Rate varied between 20 and 8713 per man. UI. CONTROL STRATEGIES 3.1. Vector control It was based on rotational larviciding. Vector control started in Niger in 1976; the basins of the Tapoa, Diamangou, Sirba, and the Meckrou, were under aerial larviciding. Based on the good results obtained, (prevalence< 5oh, CMFL : 0 incidence : 0) OCP decided to stop larviciding in 1989. 3.2. Treatment with ivermectin Considering the fact that the prevalence of onchocerciasis is nil in almost the entire areas, no CDTI is practised; treatment is only limited to detected cases. In all 87 patients have been treated in 26 villages with 215 tablets of 3 Mg. The district of Say is the most affected, with 63 % of the cases in 17 villages. I 3 3.3 Trainine To ensure the maintenance of onchocerciasis control gains by Participating Countries, OCP undertook the academic training of nationals as well as on-the-job training, in particular on the strategies of onchocerciasis control. 3.4 Other stratesies Information, Education and Communication (IEC), epidemiological and entomological surveillance also constitute control strategies of the disease. ry. RESULTS OBTAINED IN 2OO2 IN NIGER Today, due to the efforts made by OCP and Participating Countries, onchocerciasis is no longer of public health concern in Niger, and hence not an obstacle to socio-economic development. The formerly abandoned lands are now very repopulated (example of the Ainoma zone, where agriculture and the breeding are very flourishing). The epidemiologicaVentomological results are still excellent, twelve years after the cessation of vector control. The epidemiological trends are excellent in all the villages. Prevalence rates in the villages of the Say district were 60 to 70Yo, with an incidence, which was also very high. Today, the prevalence rates are generally lower than 5%o. Prevalence rates in the other sentinel villages vary from 0 to 2o/o, the rate of blindness is nil, and the incidence of the disease is also nil. No child born after the beginning of the control activities was found infected by the O Volvulus. Several top-level personnel and volunteers of the country benefited from training in epidemiology, entomology, ophthalmology, and other control strategies of OCP. On the whole, 42 people benefited from OCP scholarships, i.e. 6 in entomology, l0 in epidemiology, 18 in management of health services, 4 in public health, 2 in ophthalmology, 1 in administration and I in parasitology. Additionally, several health personnel had in-service training. Y. OBSERVATION Strengths Onchocerciasis is controlled in Niger: prevalence is nearly zero, incidence is nil, the rate of infectivity is nil, blindness due to onchocerciasis is nil. the formerly abandoned endemic zones are now very coveted and re-populated (for example, the zone of Aihoma in the district of Say). funding from the Dutch Government made it possible to equip two districts (Say and Tera) and the national Oncho coordination with three 4x4 vehicles, motor bikes in the health centres, onchocerciasis diagnosis equipment, audio- visual material, power generating unit and tour kit. The OCP equipped two districts (Say, Tera) and the coordination office with very sophisticated computer hardware as part of the data transfer process. It also gave out two vehicles (4x4) to the national coordination. 4 a The district teams were trained in epidemiological surveillance, health centre attendants in the technique of Oncho diagnosis and IEC, teachers and pupils in IEC. The CHWs were trained in Oncho/schisto/Guinea Worm [EC, and finally the village brigades in ground larviciding HKI deals with the IEC component. the State of Niger contributes to the payment of wages of health workers, handles water, electricity and the premises. WHO finances training/re-training, epidemiological surveillance, IEC supervision activities, the participation of the national team in intemational meetings. Weaknesses the hesitation in accepting the skin snip test is a critical problem, especially in the former villages. the mobility of health workers poses the problem of continuous resumption of training. financing is mainly from extemal assistance, which is an obstacle to the sustainability of activities of the Programme. the Community health workers work as volunteers. This is a long-term problem relating to incentives. the National Onchocerciasis Devolution Programme is behind schedule in the area of decentralization and integration of activities of epidemiological surveillance of onchocerciasis, and this is due to several reasons: since the disease has become rare, the health workers no longer accord it sufficient interest, the districts do not find financing to implement action plans, it does not have any budget allocated to the prograrnme by the State, and financing depends on extemal assistance. VI. CONDITIONS TO SUSTAIN AND IMPROVE GAINS (PROSPECTS) Accelerate the decentralization and integration of onchocerciasis control activities, so that they become effective in the districts and health centres. Continue the training and re-cycling of health workers toward the integrated assumption of responsibility for onchocerciasis Also intensify IEC for village communities and health workers of the Oncho area, because of the rarity of the disease. IEC will become our war-horse, for we know that behavioural change can be arrived at, only with a long-term action. Continue epidemiological surveillance, in order to control the level of infection in the community, to ensure the immediate detection of the disease, which will make it possible to control it quickly. Continue catching tests on the Tapoa and Diamangou, in order to detect recrudescence in time on the foci, and to take necessary actions. Continue ground larviciding on the basins of the Tapoa and Sirba in order to control nuisance. Intensify follow-ups and supervision of oncho activities in order to detect the lapses and correct them. Continue prospections of onchocerciasis and schistosomiasis in the villages of the Oncho zone. Integrate nutritional activities in the Oncho-freed zones. 5 --7 LUTTE CONTRE L'ONCHOCERCOSE AU SENEGAL Progris accomplis et Perspectives post-OCP 'I. 1.1 2 INTRODUCTION Situation de l'onchocercose en Afrique de l'Ouest avant OCP L'onchocercose s6vit en Afrique, en Am6rique et dans la p6ninsule arabique On estimait que dans le monde : Environ 122,9 mtllions de sujets sont expos6s i l'onchocercose. Plus de 17,7 millions de persorures 6taient atteintes de la maladie. Plus de 270 000 personnes 6taient aveugles et au moins 500.000 personnes sujettes i une mal voyance cons6cutive i l'onchocercose. ' L' Afrique est le continent le plus touch6 avec plus de 16,9 millions (95%) de sujets atteints. L'Afrique de l'Ouest 6tait non seulement particulidrement atteinte mais surtout elle abritait des foyers trds importants de la forme la plus grave de l'end6mie. Ces foyers 6taient localis6s notamment dans les parties septentrionales du B6nin, du Togo, de la C6te d'Ivoire, du Ghana, l'Est du Mali, le Sud du Niger et 6taient diss6min6s sur la totalit6 du Burkina Faso. C'est dans cette aire ou zone initiale couvrant 654 000 km2 qu'a d6marr6 le Programme de Lutte contre l'Onchocercose (OCP) en Afrique de l'Ouest. L'OCP s'est ensuite 6tendu aux foyers du Sud de la C6te d'Ivoire, du B6nin, du Togo et du Ghana, puisi l'Ouest du Mali, la Guin6e, la Guin6e-Bissau, le S6n6gal et la Sierra Leone. Aujourd'hui, l'ensemble de l'aire du Programme couvre I 235 000 km2, cadre de vie de prds de 40 millions de personnes. On d6nombrait dans cette zone avant le d6but de la lutte, plus de 3 millions d'onchocerquiens dont environ 135 000 aveugles. ' L'onchocercose est une maladie parasitaire. Elle est due i une filaire, l'Onchocerca volvulus. La filaire adulte qui ne se d6veloppe que chez l'homme produit des microfilaires transmises d d'autres hommes par la piqfire d'un moucheron commun6ment appel6 simulie, vectrice de la maladie. L'onchocercose s6vit uniquement dans des zones rurales, dans les agglom6rations situ6es le long des cours d'eau d courant rapide. La simulie se reproduit dans ces cours d'eau, d'ot le nom de "c6cit6 des rividres" que porte encore l'onchocercose. Les communaut6s les plus expos6es sont celles situ6es jusqu'd environ une dizaine de kilomdtres de part et d'autre des cours d'eau. ' La c6cit6, la nuisance et autres cons6quences de l'onchocercose sont des facteurs de d6t6rioration des conditions de ces communaut6s. Elles sont i l'origine de l'abandon des terres riveraines les plus fertiles par les villageois. ' IJn accord cadre sign6 en 1973 entre les Gouvernements participants et l'OMS d6finissait les limites, les objectifs, les structures de consultation et de gestion du Programme ainsi que les modalit6s de d6roulement des op6rations de lutte et les proc6dures d' 6valuation. ' Aprds approbation du rapport de la mission du Programme d'Appui aux Gouvernements en janvier 1974,le budget n6cessaire d la mise en Guvre du Programme de Lutte contre l'Onchocercose dans le Bassin de la Volta fut vot6. L'OMS 6tait alors d6sign6e comme Agence d'ex6cution. Dans un 6lan de solidarit6 internationale,22 pays et institutions ont financ6 les activit6s de l'OCP pendant prds de trois decennies. a3 1.2. Strat6gies de lutte utilis6es La principale strat6gie utilis6e est la lutte anti-vectorielle i laquelle s'est ajout6 le traitement i l'ivermectine dds 1987. Dans certaines zones, seule la lutte anti-vectorielle a 6t6 men6e et dans d'autres le traitement i l'ivermectine uniquement. Dans quelques-unes par contre, les deux strat6gies ont 6t6 combin6es. 1.3. R6sultats obtenus dans l'aire OCP L'onchocercose est maintenant 6limin6e comme probldme de sant6 publique dans toute l'aire de I'OCP. Dans quelques foyers limit6s, il importe toutefois d'am6liorer davantage les r6sultats acquis. t Prds de 40 millions de personnes sont aujourd'hui prot6g6s contre l'onchocercose et plus de l8 millions d'enfants n6s depuis le d6but du Programme ont 6chapp6 au risque de la c6cit6 onchocerquienne. 600 000 cas de cicitl ont 6t6 pr6venus Pr6sentement, plus de 25 millions d'hectares de terres riveraines ont 6t6 lib6r6s, sont en voie de repeuplement et de mise en valeur et pourront permettre de nourrir 17 millions d'individus. Il est ir signaler toutefois que les r6sultats restent i am6liorer dans quelques rares points : les affluents de l'Oti au Togo, l'Ou6m6 au B6nin, la Pru au Ghana, le Mafou et le Tinkisso en Guin6e. il. PRESENTATION DE LA ZONE D'ONCHOCERCOSE AU SENEGAL Le S6n6gal fait partie de I'Extension Ouest du Programme de lutte contre I'onchocercose en Afrique de I'Ouest (OCP) depuis 1986. Le pays est situ6 i I'extr0me ouest du continent africain, s'6talant sur 196 722 Km2. Il est limit6 au nord par la R6publique Islamique de Mauritanie, au sud par les r6publiques de Guin6e et Guin6e Bissau, i I'est par la r6publique du Mali et d I'ouest par I'oc6an Atlantique. Le climat est caract6ris6 par I'alternance d'une longue saison sdche allant d'octobre i mai et d'une saison des pluies de juin i septembre. La pluviosit6 n'est pas uniforme sur I'ensemble du pays. Les pr6cipitations armuelles sont plus importantes dans le sud of elles peuvent atteindre 1500 mm, alors que dans le nord, elles ne sont que de 300 mm par an en moyenne. Le climat est donc sah6lien ou sub sah6lien dans les r6gions nord alors que le sud, plus arros6 a un climat soudanien ou soudano-guin6en. La zone d'onchocercose occupe le sud-est du S6n6gal et s'6tale sur 35 833 km2 soit 18,2 % du territoire national. Le r6seau hydrographique de cette zone comprend essentiellement les fleuves Gambie et Falemd (un affluent du Senegaf et leurs affluents permanents ou temporaires. Sur le plan administratif, la zone d'onchocercose s'6tale sur 2 r6gions qui sont Tambacounda et Kolda. La premidre englobe 3 districts d'onchocercose (Goudiry, K6dougou et Tambacounda) alors que la Region de Kolda ne compte qu'un seul district end6mique (V6lingara). I t 4L'histoire de la lutte contre I'onchocercose se r6sume en grande partie par le traitement par I'ivermectine (Mectizan*) des populations touch6es voire tout simplement expos6es au :,t#.r. onchocerquien. Les traitements se font chaque ann6e dans I'ensemble des villages et un2'"'' passage se faisant dans 120 villages de I'ancienne zone hyperend6mique du bassin de la Gambie. Aussi, chaque ann6e se fait une 6valuation 6pid6miologique dans des villages choisis parmi un r6seau de 73 villages sentinelles pour suivre l'6volution de la maladie. III. LES ACTIVITES TRANSFEREES 3.1. Le traitement par I'ivermectine Les diff6rentes strat6gies de traitement par l'ivermectine ont 6t6 successivement men6es au S6n6gal. Ce sont les traitements par les campagnes de masse (de 1988 e 1996), puis le traitement par l'ivermectine d base communautaire (TIBC) et enfin le traitement par l'ivermectine sous directives communautaires (TIDC) depuis juin 1998. La strat6gie en cours actuellement est le TIDC qui repose sur un r6seau d'agents de sant6 communautaires, distributeurs de f ivermectine qui sont au nombre de 2 at moins dans chaque corlmunaut6 villageoise. Elle se d6roule non sans grande difficult6s mais globalement la strat6gie est soutenue par les communaut6s, les autorit6s du Ministdre de la sant6 et les partenaires, notamment I'OPC (Organisation pour la Pr6vention de la c6cit6). La commande du m6dicament qui 6tait faite par I'OCP est depuis 3 ans assur6e par le Ministdre, i travers la coordination du programme national. Elle va 6tre transf6r6e i la Repr6sentation de I'OMS au S6n6gal i partir de 2003 (i cause des taxes communautaires qui peuvent poser probldme i long terme). 3.2. Les 6valuations 6pid6miologiques Les 6valuations sont faites exclusivement par l'6quipe nationale du S6n6gal en collaboration 6troite avec les 6quipes cadres des districts depuis 4 ans. Les comp6tences dans ce domaine sont parfaitement transf6r6es au niveau des 6quipes du pays sauf par le test de pansement i la di6thylcarbamazine (DEC) qui reste jusque lir i parfaire. Il y'a eu un d6but de transfert de cette technique nouvelle d'6valuation. Les 6quipements (loupes, pinces de Holth, lames cercl6es, etc...) actuellement disponibles sont ceux de I'OCP ; des commandes ont 6t6 faites au profit des 6quipes nationales. Les 6valuations 6pid6miologiques seront poursuivies chaque ann6e sur financement local, d travers le Programme de D6veloppement Int6gr6 de la Sant6 (PDIS). 3.3. Les 6tudes d'impact de I'ivermectine sur la transmission Elles se font aussi en collaboration avec le laboratoire de biologie mol6culaire de I'OCP et nous en sommes d la troisidme 6tude au point de capture de Mako (district sanitaire de K6dougou). La premidre et la deuxidme se sont r6v6l6es peu productives (moins de 8000 simulies requises pour validation). Une 6tude speciale est en cours cette ann6e avec des dissections sur le terrain, en plus de I'envoi du mat6riel biologique au laboratoire de I'OCP. Ces sont captureurs villageois qui sont impliqu6s dans ces 6tudes. L'envoi du mat6riel biologique se d6roule bien i travers le circuit classique de I'OCP ainsi que le circuit propre au pays. Les ressources humaines sont disponibles pour la poursuite d'une telle collaboration avec le laboratoire de biologie mol6culaire de I'OCP ou toute autre institution. 5Iv. LES RESULTATS OBTENUS OU PROGRE,S ACCOMPLIS 4.1. Bilan des traitements oar I'ivermectine Tableau I : Evolution des traitements par I'ivermectine de 1988 d200I Commentaires Les traitements par l'ivermectine ont 6t6 men6s sans intemrption de 1988 e 2002. Les couvertures g6ographiques ont toujours 6t6 proches de 100% chaque ann6e et les couvertures th6rapeutiques sup6rieures i 65 % dans les communaut6s villageoises (sauf pendant les 3 premidres ann6es). Le tableau I montre l'6volution du recrutement des villages et les couvertures obtenues depuis 1988 (ann6e de d6but des traitements). Les couvertures ont toujours 6t6 satisfaisantes dans l'ensemble de la zone d'onchocercose. Les r6sultats de 2002 sont en cours de d'analyse et de finalisation. Les premiers villages totalisent 15 ann6es de traitement. Prds de 150 villages totalisent chacun une d6cennie de traitement, en majorit6 du bassin de la Gambie (le bassin qui 6tait le plus touch6 par l'end6mie). 4.2. Evaluations 6pid6miologiques 0 o//o Ann6es Nombre de villages trait6s Population recens6e (personnes) Population trait6e (personnes) Taux de couverture brut (%) Nombre de comprim6s distribu6s (6 puis 3 me) 1988 2t 4 9tt 3151 64,2 3 939 1989 53 l0 043 6 326 63,0 7 908 1990 60 tt 122 7 001 63,0 10 490 1991 83 19 856 15 661 78,9 30 369 1992 144 34 155 26 232 76,8 60 727 1993 151 57 t74 39 403 68,9 6 8428 1994 156 36 677 26 t87 71,4 51 646 1995 386 98 846 70 036 7l,l t23 360 1996 4t9 1 18 092 90 905 71,0 r29 7t8 1997 471 137 494 t02 426 74,5 147 250 1998 511 136 208 104 151 76,5 255 532 1999 547 t42 6t2 1 10 s97 77,6 301 286 2000 s90 tst 740 tzt 428 80,0 330 921 2001 602 156 988 124 159 79,1 341 115 Populations examin6es Pr6valence micro filarienne Bassin fluvialVillages P6riode des 6valuations Populations recens6es 83 44,9 o/oAvril 1987 97 79 8,8 0Avril 1996 93 131 3,9 o/o FaldmdFrandi Avril2001 t63 t39 56,3 o/oNov. 1989 185Gu6m6di6 Avril 1996 328 r92 22 Faldmd 6Avril2002 s18 388 6196 oh Nov. 1989 44 28 45,2 o/oLingu6ya Avril1996 67 39 ll,5 yo Fal6md Nov. 1989 343 t76 4l,g o/o Avril 1996 264 138 3,3 yo Nomoufouga Avril2002 486 355 2r0 o/o Faldmd Nov. 1989 107 80 49,0 oh Avril 1996 134 115 6,3 0 Satadougou - Baf6 Avril2001 t49 99 lr0 oA Fal6md Nov. 1989 t27 108 41,,2 o Avril 1996 113 98 5,8 0A Ylimalo Avril2001 159 t20 00 Faldmd Mars 1988 280 225 43,2 oh Mai 1989 315 226 9,40A Mai 1990 332 248 23,9 oA Avril 1991 343 138 7,6 yo Avril 1992 373 136 0% Baitilaye Mai 1999 512 423 lyo Gambie Mars 1988 55 44 61,7 o/o Mai 1989 56 37 61,8 0 Mai 1990 65 45 46,4 yo Nov. 1994 63 46 12,6 yo Barandou Faring Mai 2000 87 72 8,3 o/o Mars 1988 90 55 54'.6 o/o Gambie Mai 1989 134 40 60,4 o Nov. 1993 188 r28 5,0 0 Mai 1999 239 190 2,6 yo Dalakoye Avril2002 218 183 0 o/o Gambie Mars 1988 r22 79 36,3 o/o Mai 1989 145 rt2 2r,4 yo Mai 1990 153 101 34,3 yo Djendji Mai 1999 264 209 2,4 y" Gambie Mars 1988 175 133 81,9 o/o Mai 1989 188 158 51,6 0 Nov. 1993 2t9 150 0,6 0 Kabatekenda Mai 1999 2s9 214 2,3 o/o Gambie Mars 1988 r22 79 36,3 oh Mai 1989 145 tt2 21,4 0A Mai 1990 153 101 34,3 0A Avil 1992 177 87 3,0 o Djindji Mai 1999 264 209 2r4 oh Gambie Mars 1988 97 63 5817 oh Mai 1989 t20 34 44,0 0 Nov. 1993 t49 100 1,9 0h Magnankati Avril2002 t97 153 0rh Gambie Mai 1987 212 135 6216 o Mai 1988 239 87 42,3 yo Marougoukoto Badian Mai 1989 250 100 48,7 0 Gambie 7Nov. 1993 291 191 2,6 yo Mai 1999 282 143 0,7 0 Avril2001 169 t4t 0Yo Oussounkala Mai 1987 226 17t 68,4 o/" Gambie Mai 1988 234 62 34,8 0/o Mai 1989 2s3 9T 68,0 oh Nov. 1993 258 r62 5,1o/o Mai 1999 301 253 5,3 yo Avril 2002 323 240 1,3 "/o Tamba - Noumouya Mai 1987 208 159 66,0 oh Gambie Mai 1988 206 9l 18,9 yo Mai 1989 213 84 28,1oA Nov. 1993 236 r62 3,7 yo Mai 1999 333 270 1,9 0 Avril2001 359 289 1,4 yo Bantankokouta Mars 1988 203 173 Slrg o/o Gambie Mai 1990 215 t4l 45,3 yo Avril 1991 208 t24 34,9 0 Avril 1992 195 133 13,7 0 Nov. 1994 215 t23 7,4yo Mai 2000 t92 t42 3,5 o/o Koundaya Mai 1987 74 67 6412 o Koila Kabd Avril 1991 6l 4l 4l,l o/o Avril 1992 68 53 40,3 oh Avril2002 90 76 1r3 o Moulounga Mai 1987 150 105 56,3 o/o Koi'la Kabd Mai 1990 2t0 118 9,5 yo Avril2002 207 158 016 oh Sakhouya Nov. 1989 78 53 3312 o Koi:la Kabd Mai 2000 115 64 0Yo S6khoto Nov. 1989 t44 122 42,5 o/o Koi:la Kabd Avril2002 204 t45 1,4 o/o Missira Mai 1988 369 29s 41,6 o/o Koulountou Mai 1999 597 497 3r2 oh Ouba Mai 1988 160 131 5017 o/o Koulountou Mai 1999 224 t77 0,6 % Avril2002 243 180 0(,h Sounnatou Mai 1988 2t2 180 35,2 oh Koulountou Mai 1999 32r 204 3,9 o/o Commentaires: Nous avons choisi 24 villages des bassins (Gambie, Faldmd, Koi'la Kabd et Koulountorz ) qui ont fait le plus l'objet d'6valuation. L'6volution des prevalences est trds favorable et d6note certainement d'un impact trds positif des traitements par l'ivermectine. La quasi totalit6 des infections rencontr6es au cours des 6 dernidres ann6es l'ont 6t6 chez des adultes, ce qui t6moigne trds probablement d'infections anciennes. Le risque de c6cit6 est devenu nul dans les communaut6s villageoises jadis trds touch6es par l'onchocercose. Mais il 8faut reconnaitre que les pr6valences r6siduelles constituent toujours un facteur de risque de r6surgence si les traitements par l'ivermectine ne sont pas correctement poursuivis. V. LIENGAGEMENT DES AUTORITES 5.1. Mise en olace du "PLCME Il a 6t6 mis en place au sein du Ministdre de la Sant6 et de la Pr6vention, i la Division des Maladies Transmissibles, le Projet de Lutte contre les Maladies End6miques PLCME comprenant 3 maladies (paludisme, schistosomiases et onchocercose) qui b6n6ficient d'un financement et d'une attention toute particulidre en termes de lutte et de surveillance 6pid6miologique. 5.2. Financement des activit6s En dehors du PLCME, les activit6s de lutte contre l'onchocercose sont directement financ6es dans les 4 districts sanitaires i travers les plans d'op6rations annuels. Nous b6n6ficions d'un appui substantiel de I'ONG OPC dans le cadre de la mise en Guwe du TIDC qui va se poursuivre dans le post OCP. 5.3. Affectation du Coordonnateur national i Tambacounda Depuis Juillet 2001, le Coordonnateur du programme national de lutte contre I'onchocercose a 6t6 nomm6 M6decin Chef de la R6gion de Tambacounda qui regroupe 3 districts end6miques (Goudiry, K6dougou et Tambacounda) parmi les 4 concern6s par I'onchocercose. Le district de V6lingara se trouvant dans la R6gion de Kolda voisine. Cette d6cision doit normalement permettre une bonne prise en compte de la lutte contre I'onchocercose dans le post OCP. 5.4. Renforcement du partenariat En plus de I'OPC, nous comptons ddvelopper le partenariat avec d'autres pour la prise en compte de tous les aspects de la lutte en vue maintenir les acquis de la lutte contre l'onchocercose obtenus grAce au Programme de lutte contre l'onchocercose en Afrique de l'Ouest OCP. Les autorit6s ont bien pris conscience du vide que va laisser la fermeture de I'OCP en d6cembre2002. VI. LES DEFIS A RELEVER Il s'agit de maintenir voire de renforcer tous les acquis de la lutte jusque ld men6e contre l'onchocercose pour que cette end6mie ne revienne plus dans son expression ancienne au S6n6gal. Ceci est devenu possible car nous nous sommes pr6par6s en cons6quence. VU. PERSPECTIVES Renforcement de la surveillance 6pid6miologique intdgr6e des maladies du PLCME. L'exp6rience de la lutte contre I'onchocercose sera mise d profit dans la mise en Guvre des interventions ir base communautaire dans la lutte contre le paludisme et les schistosomiases, 7.1 97.2. Renforcement du TIDC avec une motivation renforc6e des ASC distributeurs de I'ivermectine, 7.3 Renforcement du partenariat pour un soutien plus fort d la lutte contre I'onchocercose. L'intervention des leaders communautaires, des collectivit6s locales sera renforc6e pour la p6rennisation des acquis. VNI. CONCLUSION La lutte contre I'onchocercose a 6t6 un succds au S6n6gal i I'instar des autres pays de I'OCP. Les ressources humaines ont 6t6 beaucoup renforc6es grtce i ce programme. C'est dire que le systdme de sant6 en a tir6 grand profit et la majorit6 des agents form6s sont encore dans le secteur de la sant6. Les r6sultats obtenus (traitements par I'ivermectine, 6valuations epid6miologiques) sont satisfaisants mais les pr6valences r6siduelles dans les diff6rentes communaut6s villageoises sont une menace (source de r6surgence) si I'on ne prend garde. D'embl6e I'on peut s'inqui6ter de I'arr0t de I'OCP mais les hommes, le regessus et la volont6 politique en place sont plus que rassurants quant d la consolidation des acquis de tant d'ann6es de lutte. ';rn' ONCHOCERCIASIS CONTROL TN SIERRA LEONE Achievements and Prospects after OCP a , I. INTRODUCTION 1 .l Onchocerciasis in West Africa before OCP ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. . It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, COte d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa (OCP) was started. The Programme then extended to the foci south of Cdte d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, Sen-egal and Sierra Leone. Today, the whole of the Programme area covers I 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. I I I Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Oncltocerca volvulus. The adult worn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuissance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in1973 between the participating govemments and wHo defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Govemments" in January 1974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidarity,22 countries and institutions financed the activities of OCP for nearly three decades. 2 a q 1.2. Control Strategies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases ofblindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II. ONCHOCERCIASIS IN THE REPUBLIC OF SIERRA LEONE BEFORE OCP Sierra Leone is one of the four countries of the westem extension area of OCP. Eighty percent of the country lies within the endemic zone of onchocerciasis. Onchocerciasis was responsible for thirty percent (30%) of the total blindness in Sierra Leone. Several epidemiotogical surveys conducted by local and foreign scientists in various parts of the country revealed that one million people are at risk, 300,000 infected and 10,000 blind due to Onchocerciasis. It resulted in blindness rate of 5,9oh in certain areas like Taia basin. Parasitological survey conducted all over the country involving 27L vtllages in all the major river basins revealed the following: l. 134 villages (a8%) were found to be hyper endemic with prevalence of 60%o and above. 2. 105 villages (387%) meso-endemic with prevalence 3. A total of 239 villages constituted hyper and meso-endemic areas ( prevalence : 47 to gg,5 % ) Community Microfilaria Load (CMFL) from 164 villages (60.8%) was between 6 and 67 microfi lariaes per snip. Between April and July 1988, OCP entomology staff and Ministry of Health conducted extensive surveys on the transmission of onchocerciasis. The result of the survey showed Annual Transmission Potential (ATPs) ranging behveen 191 and 6,142 of seven of the sites studied (an ATP of 100 and below is considered tolerable and an acceptable threshold). I t 3 D ,Amual Biting Rate in these same sites ranged between 6,223 and 76,8'73 (1000 is considered acceptable threshold.) The results of these studies led to the extension of the OCP operational area in the country, which was reduced only by the escalation of the war. III. STRATEGIES Because of the conflicts which started in 1991 in the country activities have been stopped until 2000. The two main onchocerciasis control processes of Larviciding and Ivermectin distribution came to a halt in 1996 with escalation of the war. 3. 1. Vector control The main strategy was concentrated on larviciding to eliminate the fly at the larval stage of its life cycle. Aerial larviciding started in the northem region in 1989 on Mongo, Kaba, Kolente, Seli, Bafi and Pampana basins. It was extended to the south and eastern regions in 1990 on the Taia, Sewa and Moa basins. A total of 35 catching points were established for entomological monitoring. With the escalation of the war the aerial larviciding in the south and eastem province was abandoned in 199 1 . In 1992, the aerial larviciding in the south and eastern provinces were permanently suspended by the Programme due to the fact that the simulium soubrense B have limited migratory capability. 3.2. Ivermectintreatment In 1987 ivermectin was introduced into the Programme as a microfilaricide. This is now the main thrust of the control activities. Ivermectin treatment started in Sierra Leone in 1990 on a large scale by mobile teams. Geographical coverage of the country was then high with almost every district of the endemic zone covered. The escalation of the war reduced the control measure only to ivermectin treatment, which was halted in 1996. After the break of 1996, another method for the ivermectin treatment was adoptedi the Community Directed Treatment with Ivermectin (CDTI), instead of the distribution by mobile teams. Ivermectin distribution after the break in 1996 of all Oncho control activities in the country remain to be the only control measure in progress. The CDTI involves training of health workers, training of Community Distributors, community sensitisation through the mass media, development and distribution of IEC materials to health facilities and communities, supervision of the distribution and data collection. The CDTI will cover very soon all the endemic areas. 4 tIt is preceded by an epidemiological evaluation to establish a new base line data in a number of villages in the endemic river basins. The training of the trainers was carried out and the training of the district teams and of the Comrnunity distributors will take place as soon as possible. 3.3. The trainine of nationals To ensure the sustainability of the achievements by the Participating Countries, OCP undertook the training of the nationals as well on the academic level as on the field activities. I 3.4. Other strateeies Information, Education and Communication (IEC), epidemiological and entomological surveillance are also the strategies of oncho control. IV. RESULTS IN 2OO2 4.1 Significant results in the Republic of Sierra Leone * Vector control After four years of larviciding the ATP was brought down to zero. As compared to the same time in 1988 at Musaia, Arfanya and Makwi. At Kaba Ferry and Yiffin, the ATPs were below 100 and the low transmission at these two sites were maintained by S. Yahese and S. squamosum species. At Katik and Mongere where transmission is due to S.Soubrense B, ATPs were high at 888 and 171 respectively. The results confirm the effectiveness of control even with ATP and Mongere and Katik above threshold. In December 2001, the entomological surveillance was resumed and the monthly biting rates were high above the threshold of 1000 at all the catching points. In April 2002, the biting rate had dropped to below the threshold at all the catching points in the north. The monthly transmission potential was zero in December 2001, which increased gradually until March and returned to zero in April. * Epidemiological situation A large current survey carried out in 2002 in the north part showed high prevalences. The prevalences are over 70o/o in many areas. * Ivermectin treatment The training of health workers is financially supported by OCP as well as the training of community distributors, the supervision of the distribution. The Sight Savers International contributes also financially to the implementation, the main collaborating NGO for Onchocerciasis control in Sierra Leone). 5 A total number of 301 health workers have been trained in the southern province,(enema District in the eastem province and Western Area. A current training of trainers on CDTI strategies is on going in the northem part. A total number of 5,316 community ivermectin distributors have been trained in the southern province and Kenema District in the Eastern Province. However, in 2001, Ivermectin distribution was resumed in conjunction with the ernergency health service that was in force. The Ivermectin distribution only took place in the safe areas of the Southem Province and part of Kenema District in the east as well as the displaced camps in all government held areas. In 2001, the geographic coverage was 79,04 % (141811794) and therapeutic coverage was 57,68 % (184,8501 320,438) in these areas. The treatment in 2002 in these areas is now in progress. v OBSERVATIONS * Strengths The return of peace and security to the country 1. Rehabilitation, resettlement and restructuring of communities 2. Tremendous awareness about the ONCHO and its treatment. 3. Acceptance of CDTI as indicated by the gradual increase in the ivermectin distribution coverage 4. Commitment of the govemment 5. Support by the NGO especially Sight Savers International 6. Availability of the willing staff 7. The decentralization of the health services in Sierra Leone 8. The continuous support of the OCP until the end of 2002 9. The World Bank intervention as proposed after OCP era. 10. The programme uses staff from other ministries and other units of the Ministry of Health. * Weakness Except for the OCP financial support the programme has no leverage over those staff. The vehicles in use are either accident affected or too old and need continuous maintenance The great loss in Makeni of all assets including thirteen vehicles warranted the relocation of ONCHO base in Freetown subjecting most of the present staff to internal displacement and inconviency in programme operations. The post war rehabilitation of health services has relocated experienced staff to other programmes and political positions, hence the in-experienced new National Co- ordinator. The stoppage of vector control shall prolong the control measure in Sierra Leone. 1 2 3 4 5 6 IVI. CONDITIONS TO SUSTAIN AND IMPROVE ACHIEVEMENTS - Have an effective national system of ordering of the ivermectin through the structures of Ministry of Health. - Ensure a pernanent availability of the ivermectin in the eligible villages. - Achieve the training of all the actors for the implementation of the CDTI - Obtain at each treatment a geographical coverage rate of 100 %o and a therapeutic coverage rate of at least 65 o/o in each village treated. - Prepare the decentralized teams to be able to carry out the epidemiological and entomological surveillance. - Prepare the decentralized teams to be able to collect data, to analyze them, to interpret them and to an adequate decision regarding the recrudescence. - Mobilise adequate resources on the national budget and from the partners. - Reinforce in human resources of the national team and decentralized teams. 7 aa ONCHOCERCIASIS CONTROL TN TOGO Achievements and Prospects after OCP I. INTRODUCTION Onchocerciasis in West Africa before OCP ' Onchocerciasis prevails in Africa, America and in the Arabian peninsula. , It was estimated that in the world: Approximately 122,9 million people are exposed to onchocerciasis. More than 17,7 million people were infected with the disease. More than 270 000 people were blind and at least 500,000 had visual impairment cased by onchocerciasis. Africa is the continent most affected, with more than 16.9 million (95%) victims. West Africa was not only particularly affected but most of all it had the most significant foci of the most serious form of the disease. These foci were located particularly in the northern parts of Benin, Togo, C6te d'Ivoire, Ghana, east of Mali, the south of Niger and were disseminated in the whole of Burkina Faso. It is in these areas known as the original area, covering 654,000km2 that the Onchocerciasis Control Programme in West Africa lbCf; was started. The Programme then extended to the foci south of C6te d'Ivoire, Benin, Togo and Ghana, then to the west of Mali, Guinea, Guinea-Bissau, S-enegal and Sierra Leone. Today, the whole of the Programme area covers 1 235 000 km2 with almost 40 million people. Before the beginning of the control operations, there existed more than 3 million onchocercal patients out of which approximately 135,000 were blind. 1.1 I Onchocerciasis is a parasitic disease. It is caused by a filarial (a worm) known as Onchocerca volvulus. The adult worrn which develops only in man produces microfilariae which is transmitted to other men by the bite of a tiny fly commonly called "simulie", the vector of the disease. Onchocerciasis prevails only in rural areas, in the settlements located along the rivers with fast flowing current. The simulie reproduces in these rivers, hence the name "river blindness" which is still interchanged with the name onchocerciasis. The most exposed communities are those located approximately ten kilometres on both sides of the rivers. Blindness, the nuisance and other consequences of onchocerciasis are factors for the deterioration of the living conditions of these communities and the cause of the abandonment of the fertile riverain lands by the villagers. An agreement signed in 1973 between the participating govemments and WHO defined the limits, the objectives, the of consultative structures and management of the Programme as well as the modalities for control operations and evaluation procedures. After approval of the mission report of the "support Programme to Governments" in January 1974, the budget necessary for the implementation of the onchocerciasis control programme in the Volta basin was voted. WHO was then designated as the Executing Agency. In a fit of international solidanty, 22 countries and institutions financed the activities of OCP for nearly three decades. 1.2. Control Strateeies used The main strategy used is vector control to which ivermectin treatment was added in 1987. In certain areas, vector control was the method used and in others ivermectin treatment only. In some others on the other hand, the two strategies were combined. 2 1.3. Results obtained in the OCP area Onchocerciasis is now eliminated as a problem of public health in all the OCP area. In some limited foci however, there is the need to improve on the results achieved. Nearly 40 million people are protected today from onchocerciasis and more than 18 million children born since the beginning of the Programme have escaped the risk of onchocercal blindness. 600,000 cases of blindness have been prevented Presently, more than 25 million hectares of riverain lands have been redeemed and is being re-populated and developed. This will enable about 17 million people to be nourished. It is to be noted however that, at some points, the results need to be improved. These are the tributaries of the Oti in Togo, the Ou6m6 in Benin, the Pru in Ghana, the Mafou and the Tinkisso in Guinea. II. ONCHOCERCIASIS IN TOGO BEFORE OCP Togo belongs to the eleven (11) countries, and is one of the seven countries of the original area of the Onchocerciasis Control Programme in West Africa (OCP). Twenty-eight (28) medical districts, out of the thirty-five (35) in the country are endemic, spanning an area of 41 000sq km, out of the total 56 000 sq km of the country. Thus, the programme area represents 73,21o/o of the total area of the country. The population at risk is approximately 2 ll43 434 inhabitants. Before the launching the Programme, prevalence rates were very high (88,5% at Titira) in the areas of strong onchocercal endemicity. The Community Microfilarial Loads (CMFL) were also very high (60,10 by skin snip test at Alamassou) and rates of blindness reaching 4% could be observed in certain areas (Landa Pozenda). The pre-control entomological evaluations reveal very high Annual Biting Rates (ABR) and AnnualTransmissionPotential(ATP) (93,604 and 14,003 inTetetou,52,340 and 1,211 inLanda Mono). III. STRATEGIES 3.1 . Vector control It started in 1977 in the original area, in particular on the Oti and its tributaries: the Kara, Keran and the Mo including the Savannah Areas, Kara and part of the Central Region. It extended to the south of the country (southem extension) in 1988, especially on the basins of the Mono and its tributaries (the Anie, Ogou), the Zio, Yoto (central region, of the plateau and the coastal area). The Onchocerciasis control activities started in Togo in 1977, with only one strategy based on vector control by weekly aerial larviciding, depending on the duration of development of the aquatic larval stage of the blackfly. 3 Seven insecticides (six chemical and one biological) were used in rotation, to avoid the appearance of resistance of any kind in the vector. 3.2. Treatment with ivermectin Ivermectin was introduced in Togo in 1988, in the Kara region and part of the Central region. Before 1997, it was distributed by mobile teams. Community-Directed Treatment with Ivermectin (CDTI) is carried out by the communities themselves since 1997. It started in the Kara region before being extended to the endemic prefectures of the country. Today, more than 4,300 villages are under CDTI. J.J Training of nationals To ensure the maintenance of gains by the Participating Countries, OCP undertook the training of nationals, both academically and through in-service training, particularly in control strategies. 3.4 Other strategies Information, Education and Communication (IEC), epidemiological and entomological surveillance also constitute control strategies of the disease. IV. RESULTS OBTAINED IN 2OO2 4.1. Results in Toeo On the epidemiological level In addition to the specific intervention zone (SIZ), made up of the basins of the Keran, Kara and the Mo, where the epidemiological situation is not very satisfactory, the rest of the OCP area has prevalence rates lower than 5Yo and quasi-nil microfilarial loads. In2002,54 villages out of 65 evaluated in the southern extension i.e. 88o/o, had a prevalence rate lower than 5Yo. The prevalence rates in all the villages have drastically dropped, as compared to the figures at the beginning of the Control Programme (example: Titira from 88,5 to 22 o/o; Bagan from 65,7 to 2,60A, Tokpo from 85,1 to 2,5Yo). On the entomological level In the original area, there is no apparent risk of resumption of infection (rate of infectivity at Oti-Toutionga equal to 0,2564 infective females for 1000 caught flies in year 2000, lower than the critical point of 0,5 infective female for 1000) after approximately ten years of suspension of vector control activities. In the southern extension area, the initial Arurual Transmission Potential (ATP), which varied from 362 to 14327 was reduced from 96 to 100'/o. It now varies from 0 to 65 maximum. In the specific intervention zone on the Keran, Kara and the Mo, the evolution of the entomological trends is favourable, after the reinforcement of the actions undertaken on these basins (experimental treatment on the main Oti River, resumption of larviciding stopped in 1990, on the 4 t Iower Keran and lower Kara, intensive larval prospections, and intensified manual ground larviciding): reduction of the ATP by 93o/o at Titira on the Keran, by IOO% at Landa-Pozenda on the Kara, by 98% at Bagan on the Mo. Treatment with ivermectin The objective is to treat 100% of the endemic villages, and at least 65% of the population of each eligible village. In 2001, the geographic and therapeutic coverage rates were more or less satisfactory. Geographic coverage : 97%o (4391 villages treated out of 4.540 envisaged); therapeutic coverage : l4 % (1.590.264 people treated out of 2.143.434Iisted). Ln2002 the partial results indicate 7O% of geographic coverage and 680/o of therapeutic coverage. Training On the whole, 58 people in Togo benefited from a training scholarship of OCP, namely 20 in entomology,22 in public health, I I in epidemiology, 3 in ophthalmology and2 in hydrobiology. The doctors and nurses in the endemic areas benefited from training sessions on control strategies, and Community distributors on the implementation of CDTI. V. OBSERVATION 5.1. Streneths o the CDTI is effective in all the endemic zones of the country. . There is at least a Community Treatment agent (CTA) in each eligible village under CDTI o the coordination of the NOCP, has since 2000, been placing ivermectin orders directly with MDP, on the basis of the needs expressed at the various levels. . There is a proven national epidemiological evaluation and treatment team able to detect any possible recrudescence. There are also five (5) regional teams trained in simple epidemiological evaluation. . There is a critical mass of trained personnel o Though insufficient for the moment, a national budgetary line item for onchocerciasis control exists. . There is a partner, "Sight Savers Intemational " (SS!, which supports Oncho control activities; . Formerly fertile lands, which were abandoned, due to onchocercal endemicity, have been re- populated and developed. 5.2. Weaknesses There is yet to be technical equipment for simple epidemiological evaluation in the five (5) areas, where there are already trained teams, due to the insufficiency of financial resources. Insufficient financial resources for the maintenance of OCP gains. Insufficiency of follow-up/supervision of CDTI activities. Frequent transfer of already trained personnel in onchocerciasis control, to other medical structures where they are not used any more in this field. This causes a constant need for training of the newly transferred personnel.. a a a a 5 aa O a t t vI. CONDITIONS TO SUSTAIN AND IMPROVE CDTI GAINS . To obtain 100% of geographic coverage in each medical district, and at \east 65%o (80% in the SIZ) of therapeutic coverage in each eligible village and for each treatment session. ' To provide logistics (motor bikes) to the nurses, who do not have them, for purposes of fo I low-up/sup ervi sion. . ' To find a solution to the issue of incentives of the distributers and health workers. o To work out IEC material for sensitizingcommunities. Epidemiological surveillance o To equip the regions and the coordination office with evaluation kits. o To finance the epidemiological evaluations in the villages. Entomological surveillance To set up teams of village catchers at the catching points that are representative of the river basins. To train regional and prefectoral supervisors in the other medical districts in the regions of Kara, the Central region, the Plateau and the Coastal areas. To re-deploy the health workers trained by OCP in onchocerciasis entomology in all the 28 endemic medical districts of the country. Mobilization of resources To maintain and increase, to the extent feasible, the budgetary line item created on the national budget, allocated to health for the implementation of OCP residual activities. To seek other partners for the mobilization of additional resources.a 6