Report of mission to Mozambique to assist the Ministry of health in the planning and implementation of the Rapid Epidemiological Mapping/Assessement of onchocerciasis (REMO/REA) in the northern provinces of Cabo Delgado, Nissa, Tete and Zambezia: May 28 – July 10, 1998

Report of mission to Mozambique to assist the Ministry of Health inthe planning and implementation of the Rapid Epidemiologicat Mapping/Assessment of onchocerciasis (REMO/REA) in the northernprovinces of cabo Delgado, Niassa, Tete and Zambezia May 28 - July 10, 1999 L|i7..1h',t/l ,hZ QJ 5 o z-.i tt n t,,t \r ( )( 1..\i,() t F (., zLtrntn*i. 0 -l' ,\r nt< t l)() \ttl a - N I Iu I t8 t _-:lSttA/)t ..i r,'n t ,t ( llrrr Byt Dr Pierre Ngoumou WHO/APOC Temporary Advisor Ministry of Public Health Yaounde, Cameroon tl A At I'trt,n lt_lr (' ,) 5 a ( ) l"l\ss \ l- z rrilrf zt,r \ I I/ c^Ilo , l)l t(;n IX) \'\ ./ \ z srr1,11 1 I 2Summary of accomplishments of the mission Activities Results Observations Io assisf fhe of Mozambique in the planning of the Rapid Epidemiological of Onchocerciasis 1. Training in the planning some members of the aspects not execution of REMOTREA NOTF took place in Maputo done of the REA teams execution of REA suNeys, including the use ofGPS Training took place in Milange district No training in the use of GPS was conducted ffistobesurueyed Selection of communities to be surveyed done by the REA field teams 4. Superuision of the REA field teams One supervision of Team #2 was conducted 5. Validation of the REA results Validation of preliminary results of Team#2 conducted a a GPS did not arrived in the field Training of REA teams conducted by the NOTF, but we cannot guarantee the effectiveness and the quality of this training. Classical mapping team not available National Co-ordinator not td the exercise Supervision not done by the NOTF at the trme we left the country Supenrisicn was scheduleC to be carried out by the NOTF, but most people designated had no Previous experience with REMO and with onchocerciasis Lack of dedicated transPort has prevented most of the actrvitres to take place, including the validation of REA results a a a a 3l. lntroduction and Background Until 1997, the epidemiology of onchocerciasis in Mozambique was not known. No epidemiological investigation(s) to determine the presence or the absence of the disease has ever been under taken by the Ministry of Health, the Research lnstitutions and the MedicalSchool. The literature was also silent on the topic. However, there was some concern that onchocerciasis may be present in the northern part of the country which shares the same border(s) with Tanzania and Malawi, two onchocerciasis endemic neighboring countries. The risk of dissemination of the disease across the border(s) was estimated higf, because of the cross-border migration of population, and the nomadic nature of the people liliely to be infected. \Mth the launching of the African Programme for the Control of Onchocerciasis (ApOC) in December 1995, Mozambique expressed interest in joining the new Programme. But an initial step in the process was to determine whether onchocerciasis existed or not in Mozambique; secondly to determine with accuracy its distribution and severity, the number of communilies and the size of the population likely to be affected. ln 1996, WHO/TDR funded a proposal submitted by the Ministry of Health (MOH). Under theproposal, the MOH of Mozambique was to carry out a small study in the northern part of the country, in Tete and Zambezia Provinces. The study was conducted in 1997 in the Milange district of the Zambezia province. Onchocerciasis was found to be hypo-endemic in the district. To date, the question is no longer whether there is onchocerciasis or not in Mozambique, rather where do you find the disease and the people affected, and what is its extent and severity? Four provinces (Cabo Delgado, Niassa, Tete and Zambezia) were selected for the Rapid Epidemiological Assessment (REA) of onchocerciasis exercise. We were invited as a WHO/APOC Consultant to assist the MOH during the planning and the implementation of the exercise (from May 28 to July 10, 1998). ll. Brief Description of the Geography and Ecotogy of Mozambique in relation to Onchocerciasis Mozambique is an African country situated south of the Equator, and in the East Coast of the southern region of Africa. The territory covers an area of 799,380 km., and extends from 10.27' and 26'56'latitude south and 30'12' and 41'51' longitude east. Mozambique is bordered to the north by Tanzania, to the northeast by Malawi and Zambia, to the west by 2irbrb*", to the southeast by swaziland and south Africa, to the east by the lndian ocean. The country presents a variety of landscapes dominated by high altitude and low lands, which corresponds mainly to the littoral part of the country. Because of its location in the intertropical area, the climate of the country is of tropical type with the following variations ' ln the North and Central regions, tropical humid climate characlerized by a rainy season much longer than the dry season. Mean annual temperatures vary between 24 and 26 C." ' Tropical climate of altitude, with averages temperatures usually less than 20. C. 4a a .Tropicat dry climate, in the south of the country, is characterized by a longer dry season with average annualtemperatures around 26 C. The temperatures vary according to the regions. Along the coast line, temperatures vary between 24"C and 26"C.ln the North and Central regions, temperatures are in the range of 2Z"C and 24"C. High altitude areas in Niassa and Zambezia have temperatures lower than 20' C. The majority of rivers of Mozambique take their source in neighboring countries. There are numerous river basins, about 100, but the most important are Rovuma, Lurio, Zambeze, Pungue, Buzi, Save, Limpopo, lncomati and Maputo. The vegetation of Mozambique is diversified as a result of latitude, longitude, and climatic differences. The country is roughly divided into four biogeographical regions, which do not follow in sequence as in the north of the Equator: . The forest occupies most of the country, specifically the northern region (Niassa, Cabo Delgado, Nampula and parts of Tete provinces), and some isolated pockets in the central and southern part of the country. The mountain forest is also found in the country (Niassa and Zambezia provinces). . The savanna and savanna mosaic are found in between the spaces not occupied by forest. . The littoral region is the domain of mangrove forest. Administratively, Mozambique is divided into ten provinces. Maputo, Gaza, lnhambane, Manica, Sofala, Tete, Zambezia, Nampula, Niassa and Cabo Delgado. The provinces are divided into districts, which conespond also to health districts. lll. Objective(s) of the mission Io assist the NOTF/MOH of Mozambique in the planning and implementation of the Rapid Epidemiotogical MappinglAssessmenf of Onchocerciasis (REMO/REA). Specific obiectives a a To train the members of the NOTF in the planning and implementation of the REMO exercise To train the REA field team(s) in the execution of the REA surveys, including the use of Global Positioning System (GPS) unit To select in collaboration with the NOTF the communities to be surveyed To provide supervision to the REA field teams during the execution of the surueys To carry out the validation exercise after the completion of the REA surueys. a a a 5V. Planning and Execution of REMO/REA activities During our last trip to Mozambique, March 23 to April 18, '1998, it was decided that the REMO/REA exercise should take place as soon as possible. The month of June was proposed for the beginning of activities. The activities to carry out consisted of: i. Training of the NorF in the planning and execution of REMO/REA, ii. Training of the REA field teams in the execution of REA surveys, including the use of GPS iii. Selection of Communities to be surveyed iv. Supervision of the REA field teams v. Validation of the REA results The mission was initially scheduled to take place from May 28 to July S, 19g8. But because of unforeseen events, the mission was extended by 5 days until July 10, 1ggg. We arrived in Maputo on Sunday, May 31, 1998. On Monday, we held coordination andplanning meeting with some members of the NOTF, including the National Coordinator. A tentative timetable of activities was drawn, which included a training session with the members of the NOTF present in Maputo, and another training session with the rest of the members of the NorF and the REA field teams in Milange district (zambezia province). 4.1. Training of the NOTF June 2, 1998, the training of the NOTF (some members) took place in the Ministry of Health. Basic principles and applications of the REMO method, as well as the theoreticat use of the GPS, were explained to the participants. 4.2. Training of the field teams in the execution of REA surveys June 3, 1998, we were supposed to flight to Quelimane , Zambezia Province, and travel by road to Milange district for the training of the rest of the members of NOTF and the REA field t-eams, unfortunately no reservation was made for me and I could join the group only on Friday, June 5,1998. Upon anival, lwas told that the REA field teams have alreidy beentrained (theoretical aspects) on the principles and applications of REMO, and that the selection of communities tobe surveyed has begun. Dr. A. Barreto, National Coordinator and Dr. Dinesh, from the University Hospital of Maputo, whose first exposure with the REMO method was on June 2, 1998 during the training of the NOTF provided the training. At this point we could not assess the quality and the effectiveness of the training provided and we were concerned that theparticipants did not have any training materials. We were concerned when we were told that in Milange district, 27 villages to be surveyed were selected; also the trainees did not have any training documents. 6June 6, 1998 we went to Mambucha, a rural community 35 km outside Milangel for the demonstration exercise of the palpation of nodules. This village was not an "oncho village" , and as we will leam later, most REA team members have never studied onchocerciasis during their training in the nursing school, have never seen a nodule, and had no previous experience with the disease whatsoever, so it would have been recommended to expose them to some cases of onchocerciasis. We were not consulted on the selection of the village; at least everything was planned before we arrived in Milange. During the exercise, it came out that one of the team (Team #1, Niassa and Cabo Delgado) did not perform well. ln a "non oncho village", they found 9% of cases. The second team (Team # 2) found 2.2o/o of nodule caniers, but performed rather better than the first group. Unfortunately, the analysis and discussions of the results of this exercise were done in portugese. li was until I asked the question whether we could look at the data that I was told that the discussions on the data have already taken place. 4.3. Training of the field teams in the use of GPS No team was trained in the use of GPS. The GPSs arrived in Maputo around June 10, 1998 and were given to the Ministry of Health. Apparently the person in charge in the Ministry did not know he niO to send these GPS to the REA field teams, until we called him and suggested that he send the GPS to Quelimane and Pemba. Dr. J. Pividaltook one GPS to Cabo Delgado on June 28, and since the mission in Pemba was canceled no training in GPS took place, and he returned to Maputo with the GPS. On July 9, 1998, the two GPSs were still in Maputo. At this date, we decided to train Dr. M. Aragon, DPC and Mr. J. Chivale in the use of the GPS with the hope that they will be the focal persons for wHo office and the MoH. 4.4. Selection of communities to be surveyed Upon retum from the palpation of nodules demonstration exercise, we embarked later rn the day in the selection of communities to be surveyed. The maps to the scale of 1:250,000 were ,."d for the exercise. They were not good enough for the exercise as they did not show relief details, which were not adequately portrayed. Also rapids were not clearly shown on the maps. On the other hand, we did not have the classical mapping team, i.e. the geographer, the entomologist, even the National Coordinator was not around during the selection of communities to be surveyed. The selection of communities to be surveyed was done by the REA field teams under the supervision of the consultant and Dr Denish. The area under study consisted of forest and forestsavanna vegetation; a grid line pattern was used where there wis no river system, as shown on the map. Along the main river system, the principle of selection based on high risk and secondary villages was used. For every high risk and secondary villages an alternative village was selected. The country was not divided into REMO divisions/Zoies because of the absence of classical mapping team. Rather we used the administrative divisions centered on the provinces. Larger provinces will consequently have more villages selected for the survey. Zambezia Province will have more villages to be surveyed than Tete Province. ' Milange is used in the text as the name of a district, and as the name of the town, headquarter of the district. 7A total of 55 villa.ges were selecled (annex attached). we have only the villages selected byteam # 2. Team #1 never made avairabre its rist oi virra'ges serected. A major limitation of the exercise was the quality of the Tgps. The maps were very ord, fromthe colonial era, so names of most villages were known diff_erenfly by the local population. Likewe also said earlier, rapids were not c6ady shown ,ni i"ri"r contour and vegetation were notproperly depicted' The fleld teams considered the number of 15 villages per province, but inbigger provinces such as zambezia, more viilages were serected. Most villages selected for..lhe.s.yrvey had an estimated population of over 1,000 people. Thisfigure would have disqualified them from the selection ,no tn" exercise. I could not find anexplanation to this but we decided to _include ,""i'riirrges in the study, having in mind thissituation which should be taken into account during the analysis of the results. 4.5. Execution of the REA field surveys Two teams, comprising 4 per_sons ('l driver, 2 public health technicians and 1 nurse) wereformed for the field surveys. we rouno these i".r. , oit ;or"rrtaffed,,. Each team covered twoprovinces: Niassa and cabo Dergado (Team #1) T";;; izambezia (Team#2). we only worked with ream # 2 in Zambezia. Most of the information in the report will reflect theexperience with this team' The NorF decided that both ,rl"r and females should be includedin the sample' The sample consisted of village r"r,o!.ir ",[rg"o in rural occupations.The participation of the communities was good, the REA team did not need an advancednotice' though in one.area, the political qu"ition'oroeionging to FRELIMo or RENAMo wasput forward to the REA team. This was however in very rare occasions. 4.6. Selection of persons to be examined The selection of persons to be examined followed the recommendations of the REM. Manual2.A minimum sample of 50 people was taken in erery ;ili;g" selecled to be surveyed. Bothmales and females were included in the sample. in int first villages examined, women eH:[xT1#Xt"I'3,:"r than that of men. lt was then decided to iicruoe ooth mates and The ideal situation is to examine two villages per day, because of long distances betweendistricts and between villages (minimal distJnce'roo[ri'r"l ,or" importanly, because of theslow start of the team in the morning the team couto piimarili examine only one village a day. we were concerned about the distribution, of villages, specifically villages that have moved tonew locations or have disappeared or have .n"rngJ-nrr"r. At each district, the team ffiffi1ti"*',ffit5,fl:l;l ;:ily'ator or the head o"r the ii,t,.i"t hospitar M;i virases were ' Ngoumou p and w.arsh J.F. (1gg3).A manuarfor Raprd Epidemiorogicar Mapping ofonchocerciasis. worrd Hearth orgrnd"tionl Document rDR/TDE/oNCHo/93.4 84.7. Supervision of the REA Field Teams No supervis ion was carried out by the NOTF at the time of our depafture' and under the oresent circumstances, it is tikely ihrt th"r" witl be no superuision, throughout the 'duration of the REA exercise' Two (2) supervision visits were scheduled for each team' The first supervision was to be carried out together with the consultant, to "[o* tn" supervisors from the Ministry of Health to famiriarize with the methodorogy. Dr: ru. V. r"i*izira from the hearth district of Mirange was in charge of the ,up"*i.ion oi rZ., + Z rur' i' Chivale' from the department of epidemiology ;;;;;;sible ior the supervision of ream # 1' Because of the lack of dedicated transport, I suggested that the first supervision of Team # 2 take place in the beginning of the netOwJrf, 'nJi[" fleld team vehicle should be used for that purpose. That way,Ee coisuttant could also train the external expert during the exercise' Most of the personnel (supervisors and.extert;;"*ertl were.Oolni the exercise for lfre flrst time and we did not think it was appropriate tor'in", io supervise/varioat" an activity they have never Jone Uetore without a proper training' It was ananged to have the flrst supervision of Team #2lake place between 'Jyne 15 and June 26, period during *il; we inoufO'Oe in ZamOezia Province. Dr M' Y'Teimizira' did not come to Quetimane and I canied the flrst .r;;;;;; 161" , she will not come until the end of my stay in Zambezia. AL".r." we could rlol tra'et to Pemba3' 1h" tup"*ision of Team #1 did not take Place. The supervision of Team #2 done by us gave the following results' .Theteamwasveryslowinthemorning,inmos.tCaseswewillnotstartbeforel0 o,clock. we suggested that tn"v-rirrt "ar[er that 10 o'clock' to be able to cover at least 2 villages Per daY' . At least the person examining patients .at.that time was very intrusive into the groin region. W-" -r".ormended tJ lr"'O this in order not to cohfuse lymph nodes with nodules. The second problem was tne fact that not knowing the nodules' several times we were ";iilG;6 confirm the presence of a nodule' . The REA team had a female who will examine mostly women' This provided the advantageofprotectingthe-prlvacyofthewomen,buttherewereSomerisksof introducing examination bias' . ln one instance the selection of people to be examined took place after a church service. . The forms were not properly filled, e'g' in most forms the category of the villages was not mentioned and on the other hand, villages, *ni"r, are known locally by a different name, were not indicated on the form' Wheneverpossibleandfeasible,weadvisedtheteamontheproblemforthefuture. Pemba is the headquarter of Cabo Delgado Province3 94.5. Validation of the REA resutts Dr J' Pividat was designated by the NorF to conduct the varidation exercise. on June 26, weleamt that the nlf was "orrpl"t"d,jn,cabo D;;;;"province. oi pirio"r decided to go tofi::H,ffi ffi :1lf, :T :5*r;",'S1x :*s u[:i#::i:l l: m e et wit h h i m i n p ", 6,, oi*. J ' J[ffi,Y:;il:,:J'Ji.',] t""#ffi#:,he varidation team r sussested that we use the ' Then there is no money for gasorine, r had no suggestion for this ' The team is no longer in cabo Delgado Province rather in Niassa province. r requestedthat the team return to pemb" -to ,J ;th is, out no action was taken. Thefundamental problem was that the teams i,onot.have a t"ntrtr" itin"r"ry in casesomebody wanted to look for them; to nouoJi knew exacfly where to find thembecause of the rack of the teniativ" iii."i"rv iJJ,],l"r,. ' The road conditions are bad, there is a bridge broken on the way, etc Finally, Dr J. pividar ,p ol!."i peoplg in the MoH advised me not to go to pemba. werequested that somebody put this in *iiting, nri."t-"ov ."r,0 take the initiatiie. 'ff':S;J:iff[T#:'::,1J1:':11;:T:l'',:?jiiln*, or the pre,iminary resu,ts or ream # z, 4.6. Preliminary results of REA and Data entry The preliminary results in parts of the Zambezia province surveyed indicate that there is noonchocerciasis at least in the area surreyeo. At the'time of oeparture from euelimane, the teamhas already visited 7 villages. in" i.iri;", tn"r" ,iiirn"".'i"r" entered into the computer. There is comoutino equipment in the o,r]:::i?r,:giogmlgrgov, quit a number of peopre are arsofiil1.j,o:Jlilf;;ffi,*,;;ruiili,,.,,,"0 Mr J chivai;r;th" ;;;;i# !ort*,.", as he 5. Conclusions and Recommendations 1' The REA survey is being carried out withou1,,thu. recording of geographiccoordinates' lt is likely thlt tne cooJrnriur *iil not be ,."loiouo during theff;'.'i'fi,i;,T;,Ir:;::::;il:not taten a'-loon as possibre Either one orthe (a) Mr' J' chivale should be trained in the use of Gps and he wiil visit eachteam in the field a.nd pass ;; il"'liowteoge to *,ur 'ihis method iscertainly effective, but by the time he'go". to the field, the teams would 4 Quelimane is the headq uarler of Zambezia province. 10 2. havecompletedtheexercise.Vr/hateverthecase,Mr.J.Chivalewas trained so tnat-ilecorro u" a focal person for the GPS in the MOH. (b) The NOTF should identify a good geoqr3plel-able to read the geographic "ooiJin"t"t trom tn6 topographical maps' This is more ieat[tii, and requires some time however' TheREAfieldteams,aswellasmostmembersoftheNoTFhavenoprevious experience with onchocerciasis, .or"or"r, ihe quality and effectiveness of the training received "r;;;t;;;u'i'nt""q e"t'ut" of the absence of supervision' and validation "*".ir!,liii fif"f, tnat tnl results of the survey would not be reliable. tt is recomm-JnOeJtnat tne ruOjF oitani=e an.effective supervision of the two REA teams. 'M;Gr; ot tn" r'rOif de"signated for the supervision must be trained, as they *iiffi tilexercise for the Rrit time' An independent expert ,rtGft" carry out the validation of the REA results' Pending the final results of the surveys lt t[-l?:: Provinces' the results obtained so far lnOirrG tf'rt there is no onchocerciasis in parts of Zambezia province, which *J*-.r*"yed. Milange appears tg P" a particular case' because of the proximity with Malawi ,nitt']" i"gree of migration between the 2 countries, it is likely thaimost of the """t "y bi imported from Malawi ?' 3 11 Annex l: Mission ltinerary and Activities May 28, 1998 . Travel by road yaounde _ Douala May 29, 1998 o Travel by air Douala _ Abidjan May 30, 1998 Travel by air Abidjan - Johannesburga May 31, 1998 June 1, 1gg8 Travel by air Johannesburg _ Maputo Meeting with the NOTF, planning of activities during the visit Training of the NorF members in Maputo on the pranning and execution of REMo Field June 2, '1998 a a June 3 - June 4, lggg . Trip to Milange via euelimane postponed ' Briefing on security measures in Maputo by Mr. Jean_Guy prante, uNDpSecurity Office(FSO) June 5, 1998 . Travel by air Maputo _ eueliman e (Zambezia province) . Travel by road euelimane _ Milange ( 50 km) June 6, 1998 Travel by road Milange - Mambucha for the field demonstration exercise of thepalpation of nodules Selection of communities to be surveyed (pm) a June 7, 1998 a a a Selection of communities to be surveyed (continued) Departure to euelimane of the team irom the MOH |.] t2 June 8, 1998 o Travel by road Milange - Quelimane June 9 -15, 1998 . Planning of activities for the fieldwork . PM/APOC called, June 16, 1998 . Travel by road Quelimane - Mocuba district June 17, 1998 . Travel by road Mocuba - Gil6 via Alto Molocu6 June 18, 1998 . Meeting with Gile District Administrator' . Meeting with the district hospital head . Primary identification of communities to be surveyed . Travel by road Gile - Murroa/Chiraco (return) June 19, 1998 . Travel by road Gil6 - Moiane (via Alto Molocu6) June 20, 1998 . Travel by road Moiane - Alto Molocu6 June 21, 1998 (SundaY) . Travel by road Alto Molocu6 - Nauela June 22, 1998 . Travel bY road Nauela - Mucina . Travel bY road Mucina - Guru6 June 23, 1998 . Travel bY road Guru6 - Muagina . Travel bY road Muagiana - Magona . Travel bY road Magona - Guru6 t 13 June 24, 1998 . Travel by road Guru6 _ euelimane June 25, 199g a National (lndependence) day of Mozambique (holiday) June 26, 199g . Travel by road euelimane _ Mocuba June 27, 1999 . Travel by road Mocuba _ Maganja da Costa . Travel by road Maganja da Costa _ Mocuba June 28, 1998 (Sunday) June 29, 199g . Travel by road Mocuba _ euelimane June 30, 199g . Legislative elections in Mozambique (holiday) July 1, 1998 . Travel by air euelimane _ Maputo July 2-3, 1998 . planning of the field trip to pemba July 4-10, 1998 July 11- 16, 1998 . Visa and flight issues to solve July 17, 1998 . Field trip canceled . Report writing . 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