Cameroon South West 2 Community directed treatment with Ivermectin project report: December 2000

CAMEROON SOUTH WEST 2 COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN PROJECT REPORT DECEMBER 2OOO * t[^Pro4 t} 2JAN, flitl \ TABLE OF CONTENTS Section 1 Section 2 Section 3 Achievements Section 4 Executive Summary Page Background Information 3 - Location 3 - Population size 4 - Date of reception of funds 4 o Total No. of communities in hyper & meso-endemic districts 4 o No of villages receiving mectizan before & No. now included in APOC project 4 o No. of times the communities/villages in the project are Have received treatment 4 o Definition of community 4 Implementation of SW 2 CDTI (2000) 4 - Project's annual training objective and the percentage of the objective achieved 5 - Types of materials developed and used for training health staff and CDDs 5 - The performance of CDDs 6 - What needs to be done to improve the quality of training of of health staff and CDDs 6 - What should be done to improve the performance of the project 6 - Mobilisation of target communities 7 - Information on the use of media and / or other local systems to disseminate information 7 - Are you satisfied with the results of mobilisation efforts? 7 - Did target communities/villages respond favourably? 7 - Suggest ways to improve mobilisation of target communities 7 Strengths and weaknesses of the CDTI implementation process - Major achievements of the project - The constraints and the challenges for the next treatment cycle - Types ofhelp you need from o The Government o APOC management o Other parties to be able to improve the CDTI process next year - Other Activities 8 9 9 9 9 9 l0 l0 ll 2 SOUTH WEST 2 COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN PROJECT REPORT (Nine months) SECTION I Background Information Location The Southwest 2 (SW2) project covers five health districts in the Southwest (SW) Province. These are the health districts, which were not covered by the SWl project. The SW province is one of the ten provinces of Cameroon. Onchocerciasis is hyper-endemic in the province. Table l. Administrative u Health districts and health areas The SW2 is situated between latitude 5" 12'and 6o 30'north and longitude 8o 30'and g" 45'east. SW2 is made of three administrative divisions, divided into l4 subdivisions and 2 districts. These divisions have been divided into 5 health districts covering 44health areas. The health districts do not strictly follow the administrative units such that a health district can sometimes cover more than one subdivision. The administrative headquarters of the province is Buea, located in SWI project area' J HEALTH AREAHEALTH DISTRICT DIVISION / SUBDIVISION /DISTRICT - Ekondo Titi - Kumbe Balue - Bamusso - Bafaka - Bissoro - Lobe - Bekumu - Bekora - Illor Ekondo Titi - Mundemba - Lipenja - Madie Ngolo - Isangele - Kombo Itindi - Idabato - Kombo Abedino - Pamol Mundemba Ndian - Bamusso - Ekondo Titi - Idabato - Isangele - Kombo Abedimo - Kombo Itindi - Mundemba - Toko district - Dikume Balue district Mamfe - Ekok - Ogurang - Kembong - Bachuo-Akagbe - Eyumojock - Tali Mamfe Afap Kendem Bakugu Kajifu - Akwaya - Amassi - Keiitu Akwa Bagundu Akwaya Manyu - Akwaya - Eyumojock - Mamfe - Upper Bayang - Mbetta - Essoh Attah - Azi - Bechati - Fotang - Foniumetaw - Njungo - Menji -Fotabong - Bamumbu -Takwai FontemLebialem - Alou - Fontem - Warbane SW2 shares boundaries in the west with Nigeria, in particular Cross River, Taraba and Benue States; in the north with the Northwest province, in the east with the West province and in the south-east with SW1 and is bordered in the south by the Atlantic Ocean. Population size The surface area covered by SW2 is approximately 10 610 sq. km and the estimated total population is 405 320 persons based on extrapolation from the 1987 census figures. We will use the population estimate of 3 16 443 persons provided by the Provincial health delegation of the Southwest province in their publication of " Information on health districts, So uthwest province, I 997' Date of reception of APOC funds: Funds for the project were received in March 2000. (t) Total number of communilies in the hyper and meso-endemic districts REA is still going on in some of the health districts. Of the 191 communities within three health districts, which have carried out REA already, 172 are hyper / meso endemmic and none of the health areas is completely hypo endemic. However quality control of REA is still going to be carried out to validate the findings since it came to our knowledge that some nurses did not follow the procedure for REA correctly. Results of Fontem have not been included because the REA was done for health areas and not communities. (ii) Number of villages receiving mectizan before and number now included in the APOC project. A few villages in Akwaya were receiving Mectizan from the Cross River project in neighbouring Nigeria before. In most of the semi-urban communities Mectizan could be obtained from the health centres and hospitals. (iii) Number of times the communities/villages in the project area have received treatment. No structured distribution of Mectizan has been carried out in this project area before. (iv) Delinition of community or village base on the term you are using Communities or villages are either made of persons of the same tribe or of heterogeneous origin living together. The size of the village can range between 8 to 4578 persons. Section 2 Implementation of SW 2 CDTI (2000) Data ls 4 #of communities / villages that decided on method of distribution #of communities / villages which decided on months of treatment #of communities / villages with trained CDDs #of communities / villages paying CDDs in cash or kind #of communities / villages #of communities / villages which selected CDDs #of communities / villages which collected drugs District 027 23 t2 83Mundemba 9t 83 51 052 22 52 0Ekondo Titi 52 102102Mamfe 102 Akwaya rl. Fontem 139 r39 t39 It is worth mentioning here that treatment started in Mamfe on the 16ft of December has not yet started in Fontem health district. As soon as REA is completed, treatment will commence in Fontem. The Kumba health district carried out district CTDI activities of two communities of the Ekondo Titi health district. *Though treatment is almost completed in Akwaya we have not been able to supervise the district nor to get any treatment figures yet. Training of the dffirent levels of stoff involved in CDTI implementation Data on activities carried out in Akwaya has not reached us, though the district medical doctor informed us that treatment was almost completed. Project's annual training objective and the percentage of the objective achieved. *The provincial staff and the radio broadcasters are same for SWl and SW2 projects. Types of materials developed and usedfor training health staff and CDDs Material used for training of health staff and CDDs is the material which was developed / adapted for the SWl project. 1. Lecture note on Onhocerciasis 2. Lecture notes on Mectizan 3. Report on Central nervous system (CNS) complications of loasis and adverse CNS events following treatments. 4. Brochure on community directed treatment with Ivermectin (CDTI) 5. Flip Charts (IEC) materials 6. Flyers on CDTI 7. Poster with lesions caused by Onchocerciasis 8. Household census/ treatment forms 5 District # of training undertaken # ofTOT trained # of district staff trained on CDTI # of health centre / post staff trained on CDTI # ofCDDs trained Mundemba 7 l8 9 9 93 Ekondo Titi 10 20 5 l5 83 Mamfe 1l 32 5 27 165 Akwaya 6 tl J t4 ,t Fontem t2 20 2 18 167 TOTAL 46 107 24 83 508 Level of training Number to be trained Number trained Percentage achieved *Provincial 0 0 District staff 15 t7 tt3% Health centre staff 148 83 56% CDDs 2532 508 20% 9. Registration/Census treatment registers I 0. C o mmunityivillage/quarter reporti ng form 1 1. Health area reporting form 12. District reporting form 13. Supervision of health centre nurse forms 14. Adverse reaction medication form 15. Adverse reaction medication stock form 16. Medication and treatment of side effects form 17. Management of severe side effects (dizziness, asthma attack, coma) 18. Serious adverse experience report, Mectizan treatment program for. 19. Mectizan reception form 20. Cost recovery form for Mectizan distribution The performance of the CDDs. Does the performance of the CDDs indicate they received and understood important information about their roles? The performance of the CDDs indicates that they received and understood the important information about their role. However, they did make some mistakes such as registering more than one family on the same page, and not including children in the counts when the population was separated into number of males and females treated. In the Bekumu health area, the CDDs did not register the children under fives years of age. Also the number of tablets to be taken were registered in some cases before distribution and such persons were ticked as treated when treated or marked refused or any other category under the column for remarks during distribution. These shortcomings will be corrected during the next round of training and distribution. The standard of understanding of the nurse was varied and this contributed to what must have been transmitted to the CDDs. In a good number of these remote health areas, nurse aids are in charge of the health centres. - lflhat needs to be done to improve the quality of training of health staff and CDDs. During the retraining sessions practical will be carried out using findings which have been observed in the field and the nurses will work with the registers from their respective communities such that all the mistake which were made can be brought out and elaborated upon. We will also have the Doctors and other district staff assist the nurses in the training of the CDDs. - If the annual objective was not achieved, suggest whst should be done to improve the performance of the Proiect. We estimated to train 148 health centre staff. These included persons of the dialogue structure and of the mission (religion) health services. It turned out that members of the dialogue structure were not invited while there were no persons from mission health services in these health districts. The number of CDDs estimated to be trained based on the proportion of 2 CDDs of 250 population was2532. We observed that the communities did not easily come up with CDDs, p.iror,r ready to do voluntary work. We will encourage the communities to select more CDDs for the next treatment round. 6 Mobitisation and education of Target communities * One NGO staff participated in mobilisation of some communities. ** Health committee members, chiefs and opinion leaders of certain communities were also involved in mobilisation. Provide information on the use of media and / or other local systems to disseminate information? At the provincial level, the South West Provincial Radio Station was greatly involved in sensitisation and education of the public. Special programs and slogans were prepared in English, French and local languages. Radio Kembong, a local radio station in Manyu Division (Mamfe Health District) also played a good role in educating their local population on CDTI in English, Pidgin English and vernacular languages. In the individual communities town criers were used for information dissemination especially calling people together whenever a health talk is to take place. Are you satisJied with the results of mobilisation efforts? Despite all efforts put in to ensure adequate sensitisation and mobilisation of the population, the turn up at most community meetings is low thus information does not get to everybody. The communities could be encouraged to participate at these meetings by the participation of district, provincial or NGO staff. Did target communities / villages respondfavourably? Most of the target communities / villages responded favourably. However not all the members of the community responded favourably. We will have to conduct sensitisation and mobilisation in the comprising of central level staff. Suggest ways to improve mobilisation of target communities. To improve mobilisation, more chiefs and quarter heads and opinion leaders should be involved. Mobilisation teams should also consist of district, provincial and / or NGDO staff. 7 District #of communit ies / villages mobilised # oftarget communities / villages which received HE about importance of extended treatment # ofadvocacy visits to State / Regional / Provincial Directors of health # of MOH staff involved in mobilisation # None MOH staff involved in mobilisation # of NGDO staff involved in mobilisation Mundemba 90 90 t2 ) ,1. Ekondo Titi 52 52 15 4 (141)** * Mamfe 102 102 20 8 ,r Akwaya Fontem 139 139 20 0 ,1. Section 3 Achievements Treatment is still going on and all data has not been collected from the field yet l. Treatment Coverage rate treated x 10 Total (census) population 2. Total (census) Population Total village or total community population in hyper and meso - endemic areas only 3. Eligible Population Total population minus those excluded. Treatment figures included in the table are from 7 health areas in Ekondo Titi health district. Treatment figures for all the other health districts are not yet available. Describe brieJly whether the proportion of village / community members who where absent during treatment is higher than expected. Treatment is still going on however from the results obtained so far the proportion of people absent or who refused treatment is high. Some of the villages are fishing village where migration is very high while refusal was high because of fear of side effects. - State the most common reasonfor absenteeism and refusals. The most common reason for absenteeism is migration especially in the fishing communities, that ofrefusal, is the fear ofside effects. Suggest what actions need to be taken by the proiect to reach absentees and defaulters during the next treatment and d any constraints might prevent their inclusion. Sensitisation and mobilisation needs to be intensified. Treatment should be given during the dry season and out of the farming season. Treatment should be given at a central location where the chief can have all community members gather and be treated on the same day. 8 District # oftarget communities / villages treated #of eligible persons treated Cost per person treated #of communities / villages in which CDD is a health worker #of distributions supervised by health workers # oftreated communities / villages with summary forms Mundemba 90 8 89 90 Ekondo Titi 52 89s6 5 73 52 Mamfe 4 Akwaya Fontem 139 Section 4 Discuss the strengths and weaknesses of the CDTI implementation process. For example, how did CDDs chosen by the communities perform their tasks; willingness or not of communities to participate in CDTI process- lo collect the drug and to take charge of distribation and its supervision. Most of the CDDs selected performed their tasks well though they needed to be supervised for good results to be obtained. Also these CDDs have their farming and other occupations to do especially as their communities hardly ever aided them. Apart from the SSI and APOC no other body provided funds in cash for the program. However the government provides staffing at the level of the provincial delegation, health districts and health areas. Also CDTI is integrated in the minimum package of activities carried out at all levels of the district health system. In this way funds earmarked for other public health activities could be used for CDTI. Major achievements of the proiect; CDTI has helped to reinforce the district health system. It has made the public aware of the existence Onchocerciasis as an important health problem with a cure. It has also made the health personnel realise that the community could be actively involved in activities pertaining to their own health. the constraints and the challenges for the next treatment cycle Side effects make some people unwilling to take mectizan. Some health areas have no health personnel while the rest have very a limited staff. The project did not have a co-ordinator for the first seven months of its existence. The community does not consider CDTI activities as theirs. They still need to claim ownership of the program. As a challenge the health personnel need to be more aggressive in carrying out health education, sensitisation and mobilisation in order to increase coverage and make the community realise that they have to claim ownership of the project. Some communities were not easily accessible. Types of help you need from: The Government The Government should make all health centres and district health services functional by adequately staffing and equipping them. Also at the district level there should be a budget line for Onchocerciasis control activities. - APOC Management Equipment in particular motorbikes approved for in the project should be provided. 9 - Other parties to be able to improve the CDTI process next year The community needs to effectively claim ownership of this program. Other activities A survey on the prevalence of Loa loa was carried out in Mundemba, EkondoTiti and Fontem. The results obtained were as follows District Number of communities examined Number of communities with Loa loa Number of persons examined Number with Loa loa Mundemba t6 t4 1001 69 Ekondo Titi 14 14 956 176 Fontem 9 9 999 127 l0 Executive Summary The South West II Project (SW 2) which is found in Ndian, Manyu and Lebialem administrative divisions consists of five health districts; Ekondo Titi, Mundemba, Mamfe, Akwaya and Fontem. These districts together have 44 health areas with 139 villages (Akwaya not included) Activities in SW 2 started in march 2000 on the receipt of funds, without a coordinator, whose appointment only came seven months into the programme. Prior to the commencement of activities, Sight Savers Intemational carried out a survey to determine the prevalence of Loa loa in Mundemba, Ekondo Titi and Fontem health districts. CDTI activities started with training. The following people were trained;107 trainers of trainees, 24 district personnel, 83 health centre staff and 508 CDDs. After the training then came successively sensitisation and mobilisation, registration, REA oncho and mectizan distribution / management of side affects. These activities have not however taken place without any difficulties. CDDs made a few mistakes in filling the registers and in the actual registration exercise itself (Bekumu Health Area in Ekondo Titi Health District left out children less than 5 years old). Since most of these CDDs are not compensated by their communities they do not put in as much time and effort as required. REA oncho was not well understood by some. Instead of village by village, Fontem and part of Ekondo Titi Health District thought it was to be done health area by health area. As a result of this mistake they will have to / had to redo the REA. No health area has completely finished treating yet. It is even worth mentioning that Fontem Health District is still to start treatment. Side effects are managed concurrently with treatment. This programme forms part of the minimum package of activities of the district health system and is carried out together with other public health activities. ll