History of Ivermectin treatment in communities in Ghana: treatment in hamlets and other settlement areas around New Longoro and Kyingakrom, report on main findings, 18th -24th February 2008

nAfrican Programme for Onchocerciasis Control (APoc) Ilistory of Ivermectin treatment in communities in Ghana Treatment in hamlets and other settlement areas around New Longoro and Kyingakrom Report on main findings 18ft-24ft February 2008 by Tiiman Diarra, Social Scientist Inter<ountry Sapport Team (IST)/ Malaria West Africa March 2008 Exccutive sumrnary This report is complementary to the previous one submitted after the November 2007 mission to Ghana. It documents the history of onchocerciasis treatment with Ivermectin in the hamlets and the other settlement areas around Kyingakrom and New Longoro in Ghana. The study was conducted with national field assistants using the same methodology as in the November 2007 study - mainly qualitative research methods - interview of key informants and the main actors in the implementation of onchocerciasis at community level; observatioq and review of records on the treatment. The study covered 28 hamlets or settlement areas. The study team used questionnaire to assess ivermectin treatment coverage in the communities. Five individuals were selected randomly from each village to respond to the questionnaire and the research method used was different from the one on geographical and therapeutic coverage. The focus was on the history of these hamlets and their involvement in the treatment of onchocerciasis with ivermectin. A community mapping was used to complete the information available through the health services. This mapping enabled the team to capture a more complete picture of the population living in the areas around Kyingakrom and New Longoro. Only hamlets and settlement areas within a radius of 20 kilometres around Kyingakrom and New Longoro were included in this survey. The main conclusions of the previous study showed that not all the individuals eligible for the treatment were treated. The hamlets did not benefit from all the rounds of treatment carried out in the main communities there are linked to. The implementation of the treatment in the hamlets is not consistent. The hamlets are not taken into account as a treatment site. The inhabitants have to move to the main community Kyngakrom, New Longoro, Ayorya for example to get treatment. The heads of households go to the main community to obtain drugs for the treat of members oftheir families. In some cases the CDDs go to treat the individuals in the hamlets, while in some cases drug is sent to the hamlets for the treatment of inhabitants' In some recent cases a CDD is chosen in the hamlet to administer the treatment But in some cases some hamlets were neither registered for treatment nor received any treatment. Ef[ective treatment is a problem. Many individuals in the hamlet do not go for treatment. In some cases individuals or heads of households who go to obtain drug do not always find the drugs due to shortages in the main community. The CDD do not always go to administer treatment in the hamlets. a For these reasons the geographic coverage is hampered while the therapeutic coverage is even rnore diffrcult or impJssi6'teio determini in the current implementation pattern. Absentees in the hamlets at the time of the treatment are never treated. The quantity of drugs sent to the hamlets are not always enough in most cases. .Some hamlets are not taken into account in the treatment and treatment is very irregular in the hamlets which have less rounds of treatment than the main communities they are linked to' Further more, reported treatment coverage is based on estimates or speculation- The eligible population is nof known in most of the communities as already shown by the November 2007 rrrOy. Even when the records are available there is no information on the population eligible for treatment. The hamlets are not always new settlements. Their age of existence vary from two years to 43 years. Effective geographic and therapeutic coverage is impeded because the settlement pattern ts not taken into account. Conslquently, some hamlets have not experienced a long and continuous exposure to ivermectin. ftris may be applicable to Kyingakrom and New Longoro where therapeutic coverable is likely to bi poorer than reported based on the situation in Kyingakrom and New Longoro. There is a need to address this issue in the implementation of the onchocerciasis control in the endemic parts of the country because other ctmmunities also have hamlets. There is also the need to tailor the implemeniation strategies to the settlement pattern and to the migration as a common phenomenon in the area of Kyngakrom and New Longoro. So recommendations made in the previous report with regard to this situation are still valid. But specific recommendations are made for effective treatment of the hamlets: making every hamlet a treatment site; having a separate record or register for each hamlet; appointing and training CDDs for the hamlets which do not have a CDD, updating everyyear the situation of the poluhtion the main communities and in the hamlet to obtain the figures for adequate prwision of ivermectin; improving the records on the treatment in the main communities' J l.INTRODUCTION After the publication of scientific papers on studies in Ghana claiming resistance of the adult Onchocerca volvulas to ivermectin as a result of possibte long exposure to the drug, APOC and the Ghanaian authorities decided to conduct further investigation on the subject to assess the situation.. A study was conducted in November 2007 addressing the issue using a protocol developed in Octobei 2007 inOuagadougou. This study was to assess the geographic and the therapiutic coverage. As a component of this study a survey has been conducted on the history of the treatment with ivermectin in the main communities where the studies claiming a resistance of adult Onchocercavolvulus were conducted. The first study of two weeks sought to assess the situation of distribution of ivermectin in the country and also to: o Document the history of ivermectin treatment in communities reported by Lancet as well as in some neighbouring communities; o Report on differencis, if any, between coverage rates provided by community-directed distributors, health personnel and (coverage rates) based on information from communities o Identify endemic communities with low coverage ratg and document reasons for low geographic coverage. A report was provided on the geographic and therapeutic coverage and another on the history of the distribution of ivermectin based on the above terms of reference. The study conducted in 2l primary communities drew the attention on the existence of other settlements areas which were not benefiting equally from the treatment. The study in February was to assess further this situation. It was specifically to: o Document the history of ivermectin treatment in all communities ( mapped and unmapped hamlets, urd firhirg communities) around , and in particular, west of the pri-aly study community of Kyingakronr, and of New Longoro within 20 kimometers iadius in thekintampo are4 excluding communities from which data has been already collected in November 2007; o Report on differences, if any, between coverage rates provided by community-directed distributors, health personnel and (coverage rates) based on information from communities o Identify endemic communities with did not regularly receive ivermectin and those with very low coverage rate, and document reasons for low geographic and therapeutic coverage. During the study in Novemb er 2OO7 the team covered all the primary communities. From the information coliected in these communities it appeared that some communities had many hamlets around and the treatment in these settlement areas was a problem. The study in February 2008 was to find out more about this situation and to assess its impact of the treatment with ivermectin in the areas around Kyingahrom and New Logoro' 4 The study has been conducted using the methodology of the survey in November 2007 but including specific issues related to the settlement pattern and the treatment, with the focus on the community level. 2. METHODOLOGY. The methodology is the same as the one used during the study in November 2007 including qualitative and quantitative methods for the study, although greater emphasis was placed on qualitative method using interviews at different levels. The interviews were conducted mainly at community level. The national, regional and district levels were not included. 2.l.Interviews at the community level involved: a Village chiefs, community leaders, the heads of the communities living in the hamlets and other settlement areas, the history of the hamlet or the settlement area, the number of households; the total population of the hamlet, the date of creation of the hamlet, the former locations of the community before the creation of the hamlet and the time in these locations, the surrounding hamlets or settlements, the nearest, the more remote one, on first year of treatment, last year of treatment, number of rounds of treatment and reasons for no treatments in some years. The interviews also covered stock out of drug during treatment, number of stock out of drugs, change of the CDDs, number of changes of the CDDs, changes in village leadership, mode of treatment (location), and change in the mode of treatment and reasons for change. The other elements were on consumption of drug (directly observed or no! given to head of the household or somebody else), community role in the distribution of ivermectin including procurement of drug, incentives to CDDs, monitoring of the treatment, treatment coupled with village events and which events; refusal of treatments, exclusion from treatment and which group; nuisance from black flies ( in the village, at work place and period); perceived benefits of ivermectin treatment in the village; major problems faced in the distribution of ivermectin in the last ten years; actions to solve these problems; willingness to continue to take ivermectin, and suggestions to improve the implementation of onchocerciasis control in the community. Other elements were added based on the information provided. A specific exchange wirs arranged with new comers in the villages, to ascertain the periods of migration; the type of migration (individual or family); area from which individuals migrated; management of treatment of migrants; management of treatment of absentees. Zonal Coordinator, on the support provided to the CDDs, the challenges faced in by the coordinator in hiVher work, the health programmes in which he/she was involved; willingness to continue; and suggestions to improve the implementation of onchocerciasis control in the zone. The study team met only one Zonal coordinator in Ayorya. CDDs were asked about new comers in the village, the periods of migration in the villages; the type of migration (individual or family); the area where individuals migrated from; management of treatment of migrants; management of treatment of absentees; existence of hamlets, fishing locations or new locations of the population; farming activities and treatment period; migration out of the village; periods of migration; management of the treatment of migrants; mode of distribution; period of o 5 a distributiorq duration of distribution; shortage of drug during distribution, actions taken with regard to shortage; support from the communities; support from the health personnel; supervision and period of last supervision; issues discussed during the last supervision; number of CDDs, refusal oftreatment;willingness to continue to work as CDD, involvement in other health programmes, suggestions to improve the treatment in the community. This interview was conducted were the information was not readily available. The interview with the CDDs had a second component on treatment records. This was done even it was done in November 2007 to assess what was done between the two survey periods. A quantitative method was used for two aspects of this study involving: 2.2. Questionnaire on the treatment In each community, five members were selected randomly either in the household or in the streets but at different localisations. The individuals selected were given a short questionnaire. The information collected included on: full names of the interviewee, name of the head of household; male or female; treated for onchocerciasis or not; if treated, an assessment of the treatment for the last three years, how long the individual had been living in the community; if not a native of the community, places where the individual migrated from and their locations and the duration at each place. But in three hamlets we couldn't get 5 individual presents. In some cases we went to the farms to do or to complete the survey' The assessment of individual treatment history was carried out through 2004, 2005,2006, 2OO7 and 2008 even the year was only at its beginning. 2.3. Cross checking of CDDs records This was to assess o The individual treatment history over the last three years with records related to the treatment in other years. o The update of the population eligible for treatment with regard to new settlers in the community in order to capture events related to the treatment o The time reference with regard to the treatment of community members o The recording as a requirement for the treatment to facilitate the management of the treatment by the CDDs. o The completeness of records and the compliance by members of households to treatment and duration of treatment in the community. o The summary report on the treatment o The effectiveness of supervision (the summary report provides one page for remarks by the supervisors on the information obtained from the supervisory visits. o The way the documents were kept o 6 This was done as in November 2007 The cross-checking process was conducted with one of the five community members surveyed randomly. It should however be emphasized that this process was not to assess coverage, but the procedures related to information on the treatment and on the activities of the CDDs. During the cross-checking (for periods where the records were available), the CDD or CDDs were on standby for interviews by the study team. 2.4. Feed back on the cross checking Questions were asked to assess the frequency of supervision during supervisory visits or if supervision took place without any record prepared by the supervisors. During the feedback session the CDD or CDDs were encouraged to continue with the record keeping as required. Where any lapse was observed appropriately advice was given with emphasis on the importance of records and record keeping as proof of work. The CDD or CDDs were encouraged to ask questions with regard to any aspect of record keeping. The cross-checking exercise equally provided an opportunity for feedback to the CDDs. The study team also arranged for exchanges between five community members selected randomly and the CDDs. There was information for instance about cases where individuals failed to take treatment while the CDDs also talked about the challenges of their work. The methodology designed by the study team ensured that there were several sources of obtaining a particular informatiorl and this provided a good opportunity for triangulation and some times for additional cross-checking. For the interviews at community level, a field assistant handled the translation. But in some communities the team was able to communicate directly with the community members. Because of the language facility the use of translation by the field assistant was discarded. But this was only in three communities. All the interviews with community leaders, community representatives and community members were recorded. The study team had the opportunity to talk in most of the cases with the community leaders who founded the settlements. 2.5. Informal interaction with community members The study team interacted with some community members, including those who refused to take the drug and were known by the CDDs. This was very appreciated by the CDDs who saw this as support for their work. 3. MAIN FINGINGS This report does not deal with the findings of the mission in November 2007 but is only complementary to the previous report. However it addresses some of the issues already analysed in the report on the mission conducted in December 2007. 3.1. Hamlets as old settlements in the area. There are many hamlets or settlement a^reas around Kyingakrom and New Longoro. Most of them are linked to Kyingakrom or New Longoro and their treatment with ivermectin is the 7 responsibility of the CDDs from Kyingakrom and New Longoro. But some are linked to other communities such as Ayorya, Fowoman and Weila. The hamlets in the Kyingakrom and New Longoro area have existed for a long time. The more recent one is Ahooto which is repopulated since 2005, although it might have been in existence for the past 30 years. The population migrated to new Longoro and to other areas. A few hamlets have setflld in the last iour oi fire years. This is the case with Fulani No I and Fulani N" 2. Most of the hamlets are in place for more than l0 years as indicated in the Annexes I and2 of this report. During the mission the team met the community leader who founded the hamlets. In some of the hamlets new settlers are still arriving resulting in the increase of population. Some of the hamlets are constituted by only one household. This is the case with Jibi Akura Adisa Akura, Garba Akur4 Dafa Akurq fojo Oagarti Akura. The Jibi Akura hamlet in place for 43 years is about the eldest in the area. 3.3. Implementation of onchocerciasis control in a special environment of disperse communities in hamlets and other setflement arees The situation relating to treatment ofthe hamlets. 3.2.l.Hamlets being treated in the main community. The hamlets are not considered as a treatment site. The inhabitants of these settlement a^reas have to move to the main community Kyingakrom, New Longoro, Ayorya to get treated. This situation has an impact on the effectiveness of the treatment. This is the case with Tain community, Dagarti Community, Nipanekru, Boys Quarters from where the population moved to iiyngukrom to get treatment. It is also the case with Jibi Ajurq Adisa Akurq Garba Akura, pafa ekura, Kojo Dagarti Akura where the inhabitants have to go to Ayorya for treatment. In all these cases the number of the rounds of treatment is also very low. The inhabitants of the hamlets go for treatment when they are informed. In some years they do not receive any information on treatment or the information is not glven on time. Shortage of drug is also a problem. This situation is general and inhabitants of the hamlets complain about it The CDDs too are complaining about it. According to one CDD said. "inhabitants of the hamlets are very diffiLut to reach, and the time they get the information about the treatment there is no ivermectin tablet left. The duration oftreatment is short and I do not have time to go to inform the population living in the hamlets". The same situation was reported in Ayorya where the Zoial-Coordinator in charge of the supervision of CDDs said: "This is particularly the case for the population living irrthe hamlet. This is one of our major constraints here. The drug is not enough to treat everybody''. The community leader of Tain said: "we have to go to Kyngakrom to get the drug most of the time. Every time they go for it they are told the drug is finished"' A 30-year-old lady i" SiUi- said: "I'm no more going for the drug for onchocerciasis. The drug is not enouglr- The ones in the hamlets do not get it" She has not been treated for the past nine years. 8 Treating the hamlets in the main community is an impediment to effective coverage. In addition, record on the treatment is also a problem. Many households in the hamlets who were supposed to be treated in the main community were not registered by the CDDs. 3.2.2. Heads of households getting drugs for their members The coverage would be very low if the head of the household does not go for the drugs. Since no member of the household gets treated. 3.2.3. The CDDs going to treat individuals in the hamlets The CDDs are in charge of the treatment outside the main community. In some cases the CDDs go for the treatment regularly, such as in Fulani N" I and Fulani No 2 in the New Longoro area. Since these hamlets settled they are regularly treated. There are registered by the COO for the treatment. These two cases are best practices that could be applied if there is no CDD chosen in the community for the treatment. But in most of the cases the hamlets which are expected to be treated by a CDD are not treated regularly. The hamlets only get treated if drug is available and if the CDD has time for the treatment. The CDDs said complained tliat the exercise is time consuming and that they also lacked the means of transportation and incentive. So the treatment of the hamlet by the CDDs depends on many factois. The CDDs do it when they think it is possible for them: availability of drug and availability of the CDDs themselves. Under these circumstances, treatment coverage is a challenge. Also, communities in the hamlets tend to cooperate with CDDs they are familiar with. In most cases the leader of the community requested to have CDDs selected within the community for their treatment. 3.2.4. The drug is sent by the cDDs to the hamlet for the treatmenl This is the case in some hamlets such as Nipanekuru and some times in Tain. In these situations community members are always requesting to have a CDD selected among them. In Nipanekuru a community member said: "we are sent the drug for onchocerciasis. The treatment is done by us in one day. The quantity of drug is not enough and everybody can't be treated. All those absent for travel or for work do not get the treatment. We would like to have somebody in our cofilmunity who can treat us". There is always shortage of drug. The community members of Boys Quarters are coming to get their treatment in Nipanekuru where all those living there can't have ivermectin themselves. The situation is therefore more complicated for the population living in Boys Quarters. 3.2.5. CDDs recently chosen to treat the individuals in the hamlets In some recent cases some hamlets have selected a CDD. This is the case in Chiridiano Akur4 Nuayiri, Ctdazanla., Basabasa, Bug Kwanta in Nyabea N" 1. But in some these cases the treatment has not always been regular because of shortage of ivermectin. In Nyabea No I the CDD who also founded the hamlet 38 years ago said he had received ivermectin to treat 9 only twice. He did not remember the first round of treatment. The last one was in 2006- He said : "The disease is not completely treated here. Despites some cases of refusal people like the drug for onchocerciasis here. If nothing is done we'll all be blind here one day". In Bug Kwanta the first treatment was in 2003 and the last in20}6. Since the selection of a CDD in Basabasa the hamlet has been treated four times in 2000, 2003, 2004 and 2006. Simpoa Akura which is linked to Basasbasa for treatmen! has been treated twice - in 2003 and in 2006. In some cases, even when a CDD is selected in a hamlet the treatment is not done regularly, but this situation gives more opportunity for improvement in the treatment of onchocerciasis. 3.2.6. Hamlets never treated for onchocerciasis. A hamlet like Ahontor has never been treated for several years. The hamlet had been deserted but two households are back. Based on the information provided by the head of hamlet and the community leaders ofNew Longoro more than 25 households were living at Ahontor and the population was quite big. The head of Ahontor, who has not heard about treatment of onchocerciasis with ivermectin, was suffering a visible case of filariasis. There is the urgent need that Ahontor, which has been reduced to about three households, benefit from the treatment. The settlement pattern and migration in the area should also be factored into the treatment prograrnme. This will involve updating the records in the hamlets and other settlement areas. f, so.e communities new households are springing up while others places are deserted such as Donko Kura. Given the situation on the ground, the reported geographic and therapeutic coverage are likely to be poorer than estimated. For example if we considered the estimated population living in the hamlet, Q992). The actual population living in Kyingakrom is 600 irabitants and that of New Logoro is 1764. These figures suggest that more population live in the hamlets within a radius of 20 kilometres from Kyingakrom and New Longoro than in these two primary communities. In the hamlets the treatment is in place only for few new settlements. But the situation is not the same as in Kyingakrom and New Longoro where treatment began respectively in 1997 and 1998. In New Longoro no treatment was carried out in 2005 and 2007. But even in Kyingakrom where treatment began in 1997 there is no record on the treatment for years betwien 1997 and 2OOZ .In this situation the assessment of treatment during this period is a big challenge. It is also diffrcult to evaluate the geographic and therapeutic coverage of the treatment. 3.4. Treatment coverage as a challenge Factors affecting both geographic and therapeutic coverage already addressed in the first report include -lndividuals being excluded for other reasons, hamlets not adequately taken into account; all communities not registered for the treatment' The denominator for both coverage is a challenge where all eligible population of human settlement areas are not taken into account. During this study the hamlets around Kyingakrom and New Longoro were covered. The treatment situation is provided in Tables I and table 2 of the annexes. A survey to assess coverage has been conducted. In some hamlets the study 10 team could not find five individuals to be selected randomly for the survey. But the figures are quite informative even the sample was made of 109 individuals (53 males and 56 females) only-a little more than the one during the study in November 2007 which was 105 individuals. The main results are the following: Even where the treatment of onchocerciasis is in place some individuals never got a single tablet since the beginning treatment. Among the 109 individuals randomly selected in the communities 23 had never taken ivermectin tablet: 21.|tr/o. This figure. does not bode well for the implementation pattern for the elimination of onchocerciasis as a public health problem in the affected areas.. The situation in the hamlets is not any better. Some hamlets those who have been treated have not been exposed to ivermectin for a long time. In most of the cases the number of treatment is less than five times. Orily 22 got the treatment for more than five times. Generally, the number of treatment in the hamlet is very low. Only one individual out our five received treatment for more than five times: 20.18yo. Some treatment is more or less a missed opportunity in the hamlets. Treatment compliance is therefore poor. From 2004 to 2OO7 oriy 11 individuals got treated very year (9 males and 2 females). The compliance during four consecutive years only l}.Ogyo in these settlement areas. If a longer period of time was taken it could be poorer. In many hamlets the treatment itself began recently. Compliance is poorest in the hamlet compared to the primary communities surveyed in November 2007r.But coverage during a single year is better. The poorest coverage was observed in 2007. Only 26 individuals out of 109 got treated (15 males and 1l females). This represents 23.85%. In 2006,63 individuals (33 males and 30 females) were treated (57.79yo). In 2005, 53 individuals (25 males and 28 females) have been treated: 48,62yo. The situation was similar in2OO4 with 54 individual: 49.54yo (28 males and26 females). These figures suggest that treatment is not optimal in these communities. There is inadequate response to community needs with the people requesting for more regular treatrnent, although there are some cases of refusals too. o a o Despite the low coverage, there are opportunities to improve the situation. The frst is the human resources. The CDDs are willing to continue to their work and the communities are willing to continue to take ivermectin. They made suggestions to improve the situation on the ground. 3.4. CDDs willingness and concerns. The CDDs are all willing to continue their work. But they said they faced difficulties in doing their work. These include less time for distribution of the drug and reaching the hamlets. Other concerns: The CDDs said the supply of ivermectin is inadequate in most cases. One CDD said: "My first problem is the drug not being enough to treat everybody. I work for all the community. But I'm getting complaints every time after the distribution. Those who were absent during the time of the distributiorq those who are not treated because of shortage of drug have the same complaints. You didn't keep some drug for me. You do not like me. I'm afraid about the distribution of the onchocerciasis drug. As it is not t History of ivermectin treatnent in Ghana APOC November mission 2007 o ll aalways enough I'm always in problem". The shortage of drug has been the reason cited by some inhabitants in the hamlet for not going for the treatment. The duration of distribution is considered short by the CDDs: two weeks for the distribution and for the report. When thy have to travel to treat they said the situation is worse. They suggested that they should be given one month for treatment and the reporting. The late arrival of the drug is considered a problem. For the CDDs there are periods when it is very easy to treat. People are around and are not busy with farm work. This is the best period. Treatment of the hamlets is seen as a problem. A CDD said: "I have to go to very far places. It is not easy. I'm willing to continue. But help us to reach the people frequently so they come to get the drug". [n some cases the CDD needs to go to the hamlet just to inform them that the medicine was available in the main community where the treatment takes place. Another CDD said: "Between the time you inform thenr, and the time they come, the drug is finished". The support for the work is seen as minimum. The CDDs said that despite not always getting support from the community they are willing to continue their work. They suggest"d the payment of allowance to them. One CDD suggested that some NGOs could help. But more importantly is the support through frequent contacts. A CDD said: I'm happy people have come to talk about my work. This is very important for me. If nobody comes to see me about my worlg I consider it is not important". Another CDD said: "when the drug comes regularly it is very important for us. Any problem in the drug distribution is a problem for us". He added: "If the oncho people do not work hard, we do not work hard. If they do not come, we relax in our work. They should come regularly to visit us". Another CDD who also appreciated the visit of the team used the opportunity to ask many questions about onchocerciasis. He was put through by another CDD, who the study team's guide. The CDDs do like their work. They made suggestions on improvement. To solve the problem of transportation, they asked for bicycles to facilitate their work. One suggested the provision of motorbikes. One CDD said: "Some hamlets are very fu away. It is difficult to go and inform the inhabitants." 3.5. Sustaining community commitment Community members everywhere see the drug for onchocerciasis treatment as very helpful and beneficial to them. They are willing to continue to take ivermectin, but some expressed concerns about the drug. To demonstrate their commitment members of neighbouring communities walk long distances to KyinkakronU Ayorya and Fawomang to obtain treatment. A community member in Jibi Akura said: "We like the drug. But the drug takes long to come. For this reason we are not treated". The last treatment in this hamlet was in 2004. Community members in the hamlets requested that the treatment should be regular. A community leader in Bug Kwanta said: "If the oncho drug comes, we should get it regularly. If it comes we'll take it". Another one in Simpoa Akura said: "we need the drug regularly. " Community members expressed their willingness to be more involved by getting at least a CDD among them. They said there were able community members who could be trained to do the work o o a 12 CONCLUSION The implementation of the onchocerciasis control programme within the context of migration and specific settlement pattern is a challenge and any impediment for the success should be identified and addressed. Within a 20-kilometres radius from Kyingakrom and New Longoro an important part of the population is living in the hamlets and other settlement areas. These hamlets have been in existence for between two and 43 years, and with most of them in their present location for more than l0 years. Although they are not new settlements, some hamlets are not registered for treatment. Treatment in the other hamlets is based on many factors which do not allow for adequate management. Only two hamlets can be considered as cases of best practices: the treatment in Fulani N" I and Fulani N" 2. They are registered as treatment site and so far a CDD is coming to treat the inhabitants every year in the past four and five years. This provides the evidence that the hamlets can be treated adequately by mechanisms to be put in place. In most of the hamlets the community members complained about irregular treatment and shortage of drug. Some hamlets have received treatment only in the last two years, while a hamlet like Ahontor has never been treated. The therapeutic and geographic coverage are likely to be poorer than reported based on the records coming from treatment register held by the CDDs. They are likely to deal only with a part of the population and a part of the human settlement areas. All the hamlets are not registered for treatment. When the population of the hamlet is eligible for treatment in most of cases there is not record concerning the population living in the hamlet. The review of the treatment records is needed. In all the hamlets surveyed, there is evidence of the willing of the community members to get the treatment: they are committed to it; they want to get somebody within the community to treat them. They complained about delay and irregular treatment. Sustaining community involvement and commitment in the treatment of onchocerciasis is very important for effective treatment coverage. The impediments to this should be adequately addressed. There is the urgency to tailor the implementation strategies of onchocerciasis control to the settlement pattern and the migration, especially in the Kyingakrom and New Longoro areas. The treatment of the hamlets is possible. Every hamlet can be a treatment site with its own record or register. Mechanisms can to put in place to make this happen in consultation with the communities living in the hamlets. Some hamlets have proposed that one or two community members should be selected to be in charge of their treatment. They expressed dissatisfaction with the current situation. A yearly update ofthe situation on the ground taking into account the settlement pattern and migration as a recurrent phenomenon in the Kyinkakrom and New Longoro areas, is needed. There is the need to support the implementation of the onchocerciasis control in Ghana and especially the treatment of disperse population living in the hamlets and other settlement areas. The support requires commitment at all levels. The willingness of communities to get regular treatment is evidenced on the ground. There is a need to revitalize onchocerciasis control in Ghana for better coverage. l3 RECOMMENDATIONS The recommendations made in the previous report regarding this situation are still valid. But specific recommendations are made for effective treatment of the hamlets. Based on the key findings of this study the following recommendations should be taken into consideration: o There is a need to map all the hamlets and other human settlement areas within the area of the main communities o The mapping should be updated every year to enable the determination of the eligible population *he.euer they are so that the quantification of the drug for the treatment should be more accurate. . Every hamlet should be considered as a treatment site o Mechanisms should be put in place by the national authorities and the communities to ensure effective treatment of the population living in the hamlets o There is a need to improve the record on the treatment by providing information separately on every single treatment site including the hamlet o Communities, health personnel and CDDs should have more interactions to solve some of the problems encountered in the fieatment, especially the treatment of the hamlets o Other possibilities for the involvement of NGOs in the treatment on onchocerciasis should be explored for more support to the implementation at community level. . Regular inter-community reviews by the implementers including health workers, CDDs, community representatives and other resource persons should be conducted to address implementation issues which are obstacles to effective therapeutic and geographic coverage as evidenced by the figures on the ground. o Community involvement should be reinforced using the CDTI approach and implementation ofthe onchocerciasis control in Ghana T4 ANNEXES AnneX 1: List hamlets, and other settlement within 20 kilometres from Kynkakrom * some individuals in Boys quarters got treated in Fawomang before they came at this new location ** new @mers are just building their houses and have not yet settled. No Nrnre of thc communfty I),istence from Kyingalcrom Nunbcrof houschokls Lsfilnrt d populatlon Numbcr ofnound of trceent Ycar of thc lest htahnent Ageh yeers) Gcoqrrphical Coordlnttcs Longltuile Lntitude I KYINGAKROM 0Km 98 600 More than l0 2007 Not provided w002 03.539 N08 05.983 2 DAGARTI COMMI,JNITY lKm 7 49 Not provided Not movided 25 w002 03.952 N08 06.153 3 TAIN COMMTJNITY 7Km 6 50 Not provided Not provided More fimn 20 4 NIPAI{EKURO 8km t5 150 Not provided Not p,rovided l3 w002 07.126 N08 06.093 5 WI,]LAAKURA 8Km 4 I 2t 20 I Not uovidcd 2007 2007 24 woo.z06.7@ N08 07.264 6 ALHASSA}I AKT]RA 9km l5 w002 07.203 N08 05.179 7 JIBI AKIJRA llKm I 4 4 2004 43 woo207.137 N08 04.250 8 BOYS OUARTERS 14Km I l0 l+ 2007 3 w002 08 025 N08 39 3vI 9 SIRIBUAKURA 16Km 4*. 25 Not provided Not provided 9 w002 ll.l9l N08 05.860 l0 BOFUO AKURA 19 Kmfrom Boys Quarters bybush road. But it is far from Kigakrom by passing by Fawomang 35 500 Notprovided Not provided 30 w(X)2 10.146 N08 ll.26r l0 BIJIPUA l0Km 4 8 I January 2008 20 w002 06 930 N08 08 018 ll AYORYA 6Km 144 t.t2t More than 10 2007 Mqetlmn 70 w@202-650 N08 02.985 t2 NUAYIRI NEW SETTMENT More than 6 Km and less than 7 to the first household of the comrnunity 44 323 3 2007 4 w002 02 847 N08 02.9{D l3 CHIRIDIANO AKURA 7Km 8 300 4 2@7 20 \\too202.032 N08 03.160 14 GAAZIENYE 11 km by bush road. But quite far bygoing tkough Subinso 25 200 5 2006 35 w002 01.215 N07 58.932 t5 ADISAAKURA 15 Km from JIBI AKURAbtfr more by Ayorya ( f7 km) I 5 3 2005 30 w00207302 N08 03 325 15 GARBA AKURA 15 KmfiomJIBI AKURAbUI more by Avrva( lTlgn) I 6 3 2005 l0 wo0207 323 N08 03 351 t7 DAFAAKURA 15 Km fiom JIBI AKURA but more by Avorva( lTkm) I 7 3 2005 20 w002 07 301 N08 03 3E4 t8 KOJO DAGATI AKURA 15 KmfromJIBI AKURAbut more by Ayorya( lTkm) I 3 I 2005 4 w002 07 379 N08 03 358 l9 DONKORKURA 9Km 4 l9 3 2005 30 w002 01.085 N08 05.933 15 Note 1. For the geographic coordinates the team used the one provided by the team in charge of the study on therapeutic and geographic coverage although we had collected the same information. The coordinates taken from different location in a disperse settlement pattern may differ a little bit. We used the coordinates we collected in the hamlets where the other teams did not have the opportunity to go. But they are not many. We concentrated mainly on the hamlets while the other teams were dealing in addition with other communities. Our work is complementary. Note 2: There are few cases where individual in a hamlet got more treatment than the number of rounds of treatment in the hamlet. In these cases he was in a community where the treatment took place and moved to a place he had less opportunity to be treated. It is important to note that among these communities Ayorya is not a hamlet but a community bigger than Kyingakrom. Some of the hamlets are under the responsibility of Ayorya with regard to the treatment. t6 No Name of community Distance fnom Kyingalu,om No of house holds Estimated population Number of round of treatment Year of the last treatment Age in years) Geographical Coordinates I.ongitude Latitude 1 NEW LONCTORO OKm 154 1764 More than l0 2008 NotFrovided w002 01.833 N08 08.483 2 FULANI NO 1 4Km 2 83 5 2007 5 w002 03.488 N08 08.566 3 FULANI NO 2 9km 10 7t 5 2007 5 w002 04.713 N08 0E.469 4 KONKOMB ANO2 5Km 4 45 2 2002 19 w00r s9.877 N08 06.752 5 BUG NKWANTA 13 Km 24 240 2 2006 26 w001s5.120 N0806.939 6 NYABEA NOl 17 Km 30 295 2 2006 38 w00152.555 N08 06.528 7 NYABEA NO2 14 Km 11 98 3 2W6 30 w00152.931 N08 05.400 8 BASABASA 18 Km 59 400 4 2006 43 w00151.337 N08 04.350 9 SIMPOA AKURA 19Km 5 40 2 2006 40 w00r 50.693 N0804.704 l0 AHONTOR 1l 3 23 Never treated 2 years forthe ressetllement* w002 05.828 NO8 09.130 AnneX 2Z List of hamlets and other settlement within 20 kilometres from New Longoro Ahontor was at the same place almost for about 30 years according to the community leader. The population left 4 years ago. But three households came back four years ago. But all did not leave the same year. Most of the population migrated to New Longoro and to Zamanama. t7 AnneX 3: List of deserted hamlets or other settlement areas within 20 kilometres from Kyingakrom or New Longoro Note: The information in the tables above was obtained from community leaders. Most of them were the ones who founded the hamlets. So the elrors should be minimal. For the distance we did measure them using the counter of the vehicle we were using during the mission. All the communities listed are within a radius of 20 km from Kyingakrom or from New Longoro. Some are even at equidistant from the two by different itineraries. But in some cases the distance is not as long, but due to natural obstacles like rivers. No Nrme ofconmmtty -IEEilcdfrom Kyingrlaom or New Longoro Nunbcr of houschokls F^ltfurrtcd populrtton Ncw desthetion Y€ar+ sincc dcscdon - EsrrDmcalCoordhrtcs Longituile Latftudc I FULAI.II AKI]RA 4kmAom Kyingakrorn 50 200 Nkomaza Dronan more than 100 miles from this fmmer location w00l 51.337 N08 04.350 2 KONKOMBA NOl 4kmfomNew Iongoro 5 50 Back to home towns, Kitaryo, Nkrmenza More than 3 yeafs w002 00.074 N08 07.133 3 SUSUKAKURA 7 km from NcwLongoro l5 80 Subensq Njira 3 years vl/m2 04.959 N08 08.371 4 ANLOGA 8km Not provided Not providod Not provided Not orovided \rllo02 01.868 N08 @.219 l8 AnneX 4: List of frshing places or other water sources where people stay a long part of the day within 20 kilometres from Kyingakrom or New Longoro No Name of community Distance from Kyingakrom or New Longoro Observations Geographical Coordinates Longitude Latitude I SEMBEL 4 kmfrom Kyinkakrom People stay there all the day for fishing w002 0l746 N08 05 546 2 JOHOL 2 Km from Kyinkalaom People stay there all the day for fishing w002 04758 N08 05 927 3 SOKOLEMPE 3 km form NewLongoro People stay there most of time in the day for fishing w002 0l376 N 08 09 162 4 GANAMO Close to Longoro meters New 400 People come there all the day for fishing, bath and for washing moto bikes cars .. w002 01629 N08 08 753 5 NTALANTIO lkm Pennanentplace fishing w002 0l 856 N08 09 039 19 AnneX 5: List of CDDs and other actors involved in the distribution of ivermectin at community level met during the mission Samuel Okra Kwabna Kyingakrom Johnson Numm Zonal Coordinator Ayorya William Mesah Ayorya Bernard Nyele Ayorya Adama Lamini New Longoro Samuel Gyanso Kwanta Charles Nanglabalu N yir Soumaila James Barto Nyabea N" I CBS Basabasa 20 Annex 6 Tenm members Mr. Odame ASIEDU Prograrunre Officer. Onclrocerciasis Control Progmnune HealthResearch Unit Ghana Health Senice Accra Gluna (+233) (0) 2+1-761357 Odarne_ I l -l,ri )'a hoo. com Mr. BTightALOMATU Biologist HealthResearch Unit- Gluna Health Senices. Box 18{ Accra - Ghana (+233) (0)2+-33316+2 Brielrt.AlorilahllJ'ltru-shs.org balomaht,4l.ahoo. corn Ms Sauda AHMEI) Data Manager Health Research Unit. Glrana Health Sen'ices Box 18{ Accra - Gluna (+233) (0\2++-787262 Sauda. Aluned,ZJ'hnr -ghs. org Mr. Kofi ADUM-ATTAE Nopchi Menrorial Imtitute for Medical Research Unirersitl'of Gham Legon Ghana (+233) (O)2+1-t70962 kadu nrattalr; ifl-a hoo. com Mr. Anthonl'OFORI Medical Entornologist Regional Health Directorate Ghana Health Sen'ice Box l{5 Sunlani Brong Ahafo (+233) (0) 2-l 3+60ee3 anthoruofori ri:hotmail. com Dr Chinl'ere IIKAGA Research ScientisUSerdor Lecturer Departnrent of Anirnal & Enr-irorunental Biolog; hno State. Universitl'P.M.B. 2000 O'n-erri. Nigeria (+23-r) (0)80-05+0e85+ (+23.r) (0)80{8254s76 chinruka ga,ri]'ahoo. com Dr. Tiema DIARRA. Focal Point IBC. IST. MAL ISTiMAL OMSiBurktuu Faso 0t BP 7019 OUAGADOUGOU" Burkina Faso (+226) 7883503.1 2t aMr. Dieudonn6 SOME Cottsultant APOC. IT Person e-Fi'? Il BP t09 OUAGADOUGOU tl BIIRKINA FASO (+226) 76683557 (+226\ 50302768 some lieti2.bf Mr. Sunday ISIYAKU Research Scientist/Progranune Mana ger Sightsavers Intemational I Golf Course Road. Kadrura. Nigeria (+23+) (0)62-2+8360 (+23+) (0)8033109{6s sisivakur4'si ghtsar-ers. or g Suudal jsi) aku, r=r vahoo. co. uk a 22