Rapid epidemiological mapping of onchocerciasis WHO) Africa Programme for Onchocerciasis control

RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCTASTS (REMO) rN SOUTHERN SI.TDAN, MARCH t-28,2003 MISSION REPORT FOR woRLD HEALTH ORGANZATTON (WHO) AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) OUAGADOUGOU, BIIRKINA FASO BY Dr. Mounkaila Noma Chief of Epidemiology & Vector Elimination WHO/APOC Ouagadougou, Burkina Faso Prof. B.E.B. Nwoke; Dr. I.N.S Dozie & C. M.IJ. Ajero WHO/APOC REMO Temporary Advisers Imo State University Nigeria PMB 2000 OweriArligeria March 27.2003 LIST OF CONTENT 1.0 Summary 2.0 Introduction 3.0 Materials and Methods 3.1 Study Area 3.2 REMO Training 3.3 REMO Field Exercise 4.0 Results and discussion 5.0 References 6.0 Acknowledgements 7 .0 Appendix 7 .l Mission Schedule 7 .2 List of Nationals Trained 7.3 REMO Data ]a 1.0 SUMMARY Rapid Epidemiological Mapping of onchoc-erciasis (REMO) *u, .orrducted in Southe* S.rdan, March 1' 28,2003 with the rrpport of African Programme for Onchocerciasis Control (APOC) During this study, a total of 300 villages (both fr9* REA and REMO ZOOr; were selected. out of this, ll8(39.3%) of them were either inaccessible and/ or insecure at the time of the study. REMO exercise was successfully conducted or validated in 182(60.7%) of the villages selected. The result showed that orrhotttciasis was absent in 6(3 '3%) of the examined villages while in 176(96.7%) of the villages, varying degrees of the iir.ur. intensity were observed. Out of the 176 vilLges positive for onchocercal nodule, 33(18'S%) had nodule rates of 1- 9%; 4a(25 .0%) had 10- 19% nodule rates while 82(46.6%) and 17(9.7%) had 20- 39% and 40- 100% nodule rates respectively. The integration of the data into Atlas Geographical Information system (Atlas GIS) helped to define the tommunity Directed Treatment with Ivermectin(CDTl) priority zones, where REMO needs to be refined Or carried out as well as non-CDTI zones. 2.0 INTRODUCTION From the grim background of the seriousness of the public health implications of hu*an onchocerciasis and its socio- economic impact in endemic areas, it became clear that it is no longer a disease that can be taken for granted' This encouraged wrro (as executing agency) in 197 4 with donor agencies and eleven (1 1) endemic -countries in West Africa to establish Onchocerciasis Control Programme (OCP). OCP, the largest single and most successful tropical disease control programme wal solely based on aerial spraying of breeding sites (rivers) with biodegradable larvicideJ to kill the aquatic larvae of the flies which transmit the disease. The success story of OCP has been reported severally (Duke, 1990; WHO, 1994; APOC' 2000). To sustain this success, and to confiol the disease in other endemic country outside the OCP atea, global efforts continued in search oi complementary strategy for the disease control. Recent years have seen considerable progress in the control of human onchocerciasis and the dramatic change of emphasis in strategy. The opportunity presented by the discovery and registrations of ivermectin (Mectrzan) as a safe and effective mlcrofilaricide for large-scale (mass) oral treatment of onchocerciasis was a remarkable breakthrough. This development revolutionised the disease control strategy' Infact, repeated, annual single-dose treatment with Mectizan reduces th; development of clinical illness, visual impairment, disfiguring iLin conditions and significantly decreases vector infeciivity, thus reducing fiansmission (APOC, 2000). on October Zt, tggg, Merk & Co. Inc. at a press conference took an unprecedented decision and announced that it would supply Mectizan free for the treatment of onchocerciasis to any one who needed it, for as long as necessary. This commitment, provided agencies, otganisations like OCP and endemic countries not only *itf, incentive but also with formidable challenge. This open a new chapter and opportunity; and WHO African Programme for Onchocerciasis Control (APOC) was launched ,n1ggS to take up this challenge to control the disease in 19 endemic African countries outside the OCP area. A massive consortium comprised of governments of 19 partner nations, donor countries, WI{O, Merk &' Co' Inc', TDR/WHO' world Bank, NGDOs, UNDP and FAO all came together to help established and support a novel prografiIme-APOC-to ou"rr., the distribution of Mectizan and to ensure it reached those populations most at risk. And the objective of APOC "is to estaUiish, within a period of 12'15 years, effective, seJf- sustainability and Community Directed Treatment with Ivermectin (CDTD throughout the endemic areas in the geographical scope of the piogtam*e." By this, APOC's g!!l_is to treat 50 million peopie pet year by 2010 through CDTI stratery (APOC, 200b). - Furthermore, in selected and isolated foci, IpOC aims to eradicate the vector, wherever possible, by using environmentally safe methods (WHO, 1996)' From its inception, the philosophy of APOC has been to provide Mectizan treatment 6 the people at the highest risk of developing the most severe complications (WHO, 1995 a). In this conc.!t, th. general agreement is that ivermectin should be distributed first tJcommunities that are atrisk of developing the severe and disabling ocular and dermal complications (Taylor et al, 1992; WHO, tggz). And the level of communrty's risk is directly ielated io the intensity of the disease in the community (Remme et a1,1989). This according to wHo (1992, 1995 a) and Ngoumou &walsh (1993) is usually determined epidemi[logically using Rapid Epidemiological Mapping _ of onchocerciasis (ngrr,rol In view of the foregoing, APOC requires comprehensive epidemiological data on onchocerciasis using the WHO ,e.ommended REMO from all APOC countries for effective GDTI strategy. The REMO data help to delineate the areas lzones that need CDTI priority and at the same time ensure adequate coverage of the high risk areas. In Southern Sudan, the first clinical observation of onchocerciasis was made by Ensor in 1908. Ensor described what was then known as "craw craw" in soldiers stationed in Meridi in Bahr El-Ghazal Region. About three decades after Ensor,s observation, Bryan (1935) reported a definite association of onchocerca volvulus infection with blindness and onchorrr.ul skit diseases. Infact, Bryant called oncho- blindness, "Jur blindness" because the disease was prevalent between the Jur and the Balanda near the Jur river tributaries. Since these initial studies, other works identified onchocerciasis and its vectors in the different parts of Southern Sudan, including Kirk (|g37),Lewis (1957), Haseeb et al (1962), Satti (1985), iVittiu*r et al (1985), Kaneene at al (1985), and Baker it Abdeinur (1986). 'These results though not coordinated showed that onchocerciasis and its vector species are prevalent and widespread in Southern Sudan. However, there are alot of more areas where the prevalence and distribution of onchocerciasis is yet unknown. Furthermore, the available dataare not comprehensive enough to give the needed spatial distribution of the disease. The absence of complete epiOemiological information on the disease in Southern Sudan till now tras timited APOC's complete implementation of cDTI in all the high-risk communities. It is against this background and in ,onsidetation of the current cease-fire that APOC sponsored this study with the following objectives: tul To train the 3outhern Sector onchocerciasis Task Force (SSOTF) members on REMO procedures and techniques(b) io assist the Task Force conduct REM9 exercise in selected villages and also appraise and validate the existing REAIREMO results-that will generate ,o-pr.hensive epidemiological data that will enable APOC delineate areas that need CDTI priority and at the same time ensure adequate coverage of all the high risk communitie s/villages. 6 3.0 MATERIALS AND METHODS 3.1 STUDY AREA The study area of this mission is Southern Sudan' Southern Sudan is bordered on the west by Central Africa Republic (CAR), on the East by Ethiopia and on the southern boundaries by oemocratic Republic of congo (DRC), Uganda and Kenya. ti is administratively divided into three regions; Equatorial Region on the South, Bahr El-Ghazal Region on the north west urrd tfrc Upper Nile on the north east. Each region is divided into counties (Fig 1,2). The major topographical feature of Southern Sudan is the White Nile *t lch constitutes the main drainage system. It transverses the three regions from the southern border with Uganda, DRC and cAR. In the Upper Nile region, the main tributaries of the White Nile are; Baro, Pibot, Bahr El-Jebel rivers; in the Bahr El Gazal,the main rivers are the Jur, Kiir, Pongo, and Chel while the main tributaries of the white Nile in Equatoria Region are wau, Kideopo, sue, Ibba, and Yei rivers. These rivers arise from the watei shade or headwaters of the White Nile, and therefore are fast flowing with a lot of rapids' These characteristics create favourable breeding sites for the Simulium vectors. The climate of Southern Sudan is tropical with average annual temperature of about 29C (about85F). The rainy season months are April-September with annual rainfall of more than 1000 mm (a0 inches). In Southern Sudan, the vegetation varies from typical .uioforrrt in the southern part to Guinea/derived Savannah in the northern area. There is a vast swampy and or flood plain in the Jonglei area of the upper Nile- Human settlement, though seriously affected by many years of civil war is basically rural Farming and livestock production are the main occupations of the rural conrmunities. Exposure to infection in Southern Sudan is by way of village proximity to breeding sites and occupational activities. In endemic .LI I =0 6 a 6 oI o oE oI oq I a o =o o n oI{ s, lAt, o{ -.tt =o e S6 ! LO r' U, oc Fl.IF -o - = cntr CLg, II J -rr|tsi)ts|.ts) -.v)(-FFl D9 a.fUt.I o ats. -1.U2ts. o -)a -o o -lr tl zvoto =. 0a95'iD :i=Gl =.cho !-. cL ='U' oo Noo t= rn oC {ov C!! m7 z F /: ,''!(.o' N U, otr F} =o =a tr CL A' Fe oe(D v, a F9 og Ft b.J (, Ft!z - tD Xo:tf) u)o0 f o tm .j!t=2'3Efi'gEgllot- vzlOL.EETO3E=.o!. v 5:= -&Ba ot's & Ng G6 \ \ -:. .lr''; ",/ | .1 Y1 l= O JOo 1\)oO d-l . ^r"1 communities, both old and young are exposed to infection such that the disease prevalence gradually increases with advancing age. 3.2 REMO TRAINING One of the major objectives of this mission was capacity building - to enabie the Southern Sector Onchocerciasis Task Force (SSOfp) of Sudan have a pool of well trained manpower that will train the Regional and County control teams as well as possess the capacrtylo continue successful REMO exercise in u.tut that are inaccessible or insecure at the time of the present exercise. To achieve this, a26-man SSOTF team (see appendix 7 .2) was trained for four days (March 1A44,2003) in Rumbek on all aspects of the WHO recommended Rapid Epidemiological Mapping of Onchocerciasis (REMO) documents (Ngormou and walsh, 1993; WHO, 1995 b). In addition, the team was exposed to the biology and ecology of the disease vectors, epidemiology, clinico-pathological aspects and the socio-economic impacts of the disease on the population. The team was also taught the current disease iontrot strategy adopted by WHO/APOC. At the end of the theoretical training at Rumbek, all the team members were taken to a known endemic community, Wulu in the Lakes County for a one day intensive practical (March 15,2003) on community mobilisation, use of REMO forms, clinical examination and identification of onchocercal nodule. The training was very successful. 3.3 REMO FEILD EXERCISE At the end of the practicum, six groups were formed (with a member of SSOTF as Soup leader) to carry out field REMO exercise in the accessible and secure selected (REMO )villages based on the lJN security advise. For obvious logistic and security reasons, the team to upper Nile region (Boma) had !o fly for ihi, .*..tise with a UN designated plane. Where possible urd ,.rure, the APOC team facilitated and supervised the field exercise. Having established the time-table, and UN security clearance for theirillages to be examined, adequate logistic and material supports including communication system (radio and mobile phone), all the groups went ahead with the implement tiott of the field REMO exercise (March 15-262, ZObf). At the end of the field exercise, the collated results were impressive and consistent with previously described epidemiological patterns of the disease. There is no doubt there fore that tfrit nbnno exercise in Southern Sudan is a huge success, notwithstanding the inherent difficulties associated with extensive community bised-studies in an area under civil war conditions. 4.0 RESULTS AND DISCUSSION With the support of WHO/APOC, Rapid Epidemiological Mapping of Onchocerciasis (REMO) was conducted in Southem Sudan, Idarch l-28, 2003. It is important to note here that REMO as an operational procedure is used to determine through a rapid and simple method the approximate distribution and ,.r..ity of onchocerciasis in the area andl or validate existing information and results of previous mapping exercise' This is carried out in order to provlde a rational basis for planning and implementation of cost-effective and sustainable onchocerciasis control. Against this background, on arrival at Nairobi the APOC team triO to study and appraise the historical epidemiological data on onchocerciasis from 1908 and the REMO exercise conducted by Health net International GINI) and other NGOs in Southern Sudan, lggS-2002. It was observed that the previous REMO exercise was relevant but the sampled villages lacked geographical co-ordinates (latitudes and longitudes) and lvere iot- siictly selected in accordance with wHo/ REMO procedure. 9 However, the results were consistent with known epidemiological and entomological data in Southern Sudan' Ufft.n the selection of the REMO villages for the present exercise was completed, their geogfaphical co-ordinates were directly calculated using topographical maps as the use of Geographical Positioning system (GPS) was prohibite{ l" Soutlern Sudan at the time of the exercise. Before the field exercise, consistent results of the previous REMO exercise which colresponded to villages selected in the present 1tud.V were adoptedand validated where possible. Infact, the endemic onchocerciasis village used for the practical was primarily selected to help validite the previous REMO exercise. A total of 300 REMO villages (both from REA and REMO 2003)were selected in this exercise. Out of this , 1 13(39'3%) of them were either insecure anil or inaccessible at the time of the present study. REMO exercise was successfully conducted or validated in 182(60.7%) of the selected villages. By the present result, onchocerciasis is absent in 6(3.3%) of the villages examined while in 176(96.770) villages, varying degrees of disease intensity were observed. Of the 176 vtllages positiv. It oncho cercal nodule, 33(18.8olo) had nodule rate of l'9%; 44(25.0%) villages had 10-19% nodule prevalence while gzi+o.ayi and {t1s.7%) of the villages had 20-39s% and 40- IOO% nodule rate resPectivelY. The distribution and intensity of Onchocerciasis in the exercise was integrated into Atlas Geographical Information System (Atlas CfSl $ig 3) and it was observed to be consistent with known epidemiological information of the disease in Southern Sudan. Furthermore, the same software was used to define the CDTI priority areas, no CDTI areas and where REMO should be performed ot refined (Fig. 4). From- here it is clear that bnchocerciasis is endemiCin Southern Sudan but more REMO data are urgently needed to actually define the boundaries of CDTI priority zones. 10 a otr r+' - J o - = CN C CLq, = F FIz =o F Eg F tD(r) tH - ++a ecoGO I.NJ-= -t7YY\o?a-Z o\o\00 EL Eoo s :t=o ts o f,oE aI o D Q o\ s E oGI c.t :.aI a o DB o ts oe E -tt o 3a aa o{ 'lt !o 3o a oo E Eo T oI o Lt o o o& 3 ,^tllB5lE+lEtl I ,1 I +, g, I;o1t?.- iEElr+ J lqE lH 5l1 a 13. sl9 cLlz'qtd(! - I'r J lElf) -"1 *qi -te ,u 19 ,"!t (r, B$I EEEEEOU_'0"I *ti.t=oFrE';? rE i. E.EE g< aEC-OEEAgB g x6q E -g f[::i = E6'?'E.EA;E as:' fit3s *;t aul<o 9=t =ocrl ,ga6e. E Ia s =o 0q rFlE IBIIt lBlli lsl1E IEIts lBliol=lI S lol \E lrl -l ;\]o *it\ i* F -5 o{ .: -JF'-1l>t Bit n i "l:\ rA .:. lrl1 ' ;:Iri$ *, I 6rl ?rt' tr z o CLg o o s geooo FFFE-i.(,)Ho\0\o 5.0 REFERENCES APOC(2000). Empowering Partnerships and communities : APOC and the fight to get rid of Aftica of River Blindness--- WHO African Programme for Onchocerciasis Control (APOC), Ouagadougou/Burkina Faso. Baker, RHA &Abdeinur, oM(1986). Onchocerciasis in Sudan. The distribution of the disease and its vectors. Trop. Med. Parasitot. 37:341-355 Bryant, J(1935). Endemic retino-choroiditis in Anglo-Egyptian - Sudan, and its possible relation to Onchocerca volvulus. Trans. Rov. Soc. Trop. Med. Hvg' 28: 523-532 Duke, BOL(1990). Human Onchocerciasis: An overview of the Disease. Acta Leidensia. 59OeD' 9-24 Ensor, H (1908). The advent of craw-craw in the Anglo- Eryptian Sudan. J. Roy. Army Medical corp. 10:140-143 Haseeb, MA; satti, MH & Sherifl M(1962). Onchocerciasis in Sudan. BulL WHO 27: 609'615 Kaneene, JB et al (1985). An epidemiological study of Onchocerciasis in Bahr EL-Gazal province. Sudan Med' J' 2l(suPPl .): 65-71 Kirk, R (1947). Observations on onchocerciasis in the Bahr El- Gazalprovince of Sudan. Ann Trop. Med. Parasitol 4l '357 - 364 Lewis, DJ(1957). Simuliidae and their relation to Onchocerciasis in Sudan. BulL wHo. 16.671-67 4 tl Ngoumou, P& Walsh, JF(1993). A Manual for Rapid Epidemiological Mapping of onchocerciasis (REMO) TDR/TDE/ON CIJiO t 93 -4 WHO Geneva Remme, HJ et al (1989). Ocular onchocerciasis and intensity of infection inthe cofirmunity.1. West African savannah. Tron. Med. Parasitol. 40:340-347 ' Satti, MH(1985). A historical account of Onchocerciasis in Sudan Med.J 21:5-8 Taylor, HR; Duke, BoL & Munoz,BC (1992). The selection of - communities for treatment of Onchocerciasis with ivermectin. Trop. Med. Parapitol' 43"267-270 wHo(1992).Methodsforcommunitydiagnosisof Onchocerciasis to gUide ivermectin-based control in Africa. TDR/TDE/0NCH0/92'2, Geneva wHo (lgg4). Twenty years (1974-1994) of onchocerciasis control Programme in west Africa. wHo Geneva. WHO (1995a). Onchocerciasis and its control: Report of a wrro Expert committee on onchocerciasis control. WHO Tech ReP. Ser. No 852 wHO (1995b). The importance of onchocercal Skin disease: Report of a multy county study. TDR Applied Field Research RePort, No I Geneva' WHO (1996). African Programme for Onchocerciasis Control (ApOC). programme document for phase 1. APOC Ouagadougou. williams et al (1985). Cunent distribution of onchocerciasis in Sudan. Sudan Med. J. 2l:9'17 . t2 6.0 AKNOWLEDGEMENT we are grateful to APOC for the opportunity given to us to serve in thiJ exercise and to WHO Lagos, Southern Sudan and Kenya for their efforts to facilitate our mission. We are indebted to the chairman and members of SSOTF for their support and goodwill through out the study. The success of this exercise was made compaiatively easier by the expertise and professionalism as well as commitment exhibited by HealthNet international (HNI) in generating the REA results even in the mist of civil war. The contributions of the field teams, village heads and drivers are highly appreciated. To all that contributed to the success of this study, we say thank you' t3 7.0 APPENDX 7.1. MISSION SCHEDULE AGENDA Activities r Arrival of APOC TeamFeb.28'n 2oa3 . Meeting with SSOTF,WHO/Southern Sudaru WHO/I(enYa . Collection of maps, rePorts and materials o Planning of REMO exercise (training & field exercise) . Travel clearance Mar.1-8'n 2OO3 r Departure for Lokichoggio . Arrival in Lokichoggio . Security briefing by OLS . Orientation of APOC and HNI team members (BY WHO) . Departure for Rumbek o Arrival in Rumbek Mar. 8-9" 2003 . nui"i"g on REMO methods and techniques r Selection of REMO villages/ (sampling of villages) ion for field exercise Mar. 10-14'" 22003 . Practicals o Field REMO exercise Mar.15-21*2003 for Nairobi o Dataentry, analYsis o Mission report . Planning comPletion of REMO in Southern Sudan o Debriefing SSOTF, WH0/Southern Sudan r f)enarhrre of APOC team l/rer.23-29'" 2OO3 7.2 LIST OT SSOTF TRAINED 1. Dr. Samson Paul Baba/SSOTF Coordinator 2. Dr. Samuel Patti 3. 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