Expert advisory committee ad hoc session: Ouagadougou, 11-15 March 2002, progress report by unit planning, evaluation and transfer: June 2001 to date

,/ WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTI ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFzuQUE DE L'OUEST EXPERT ADVISORY COMMITTEE Ad hoc Session Ouagadoueou. I I - l5 March 2002 EAC.AD.I Original: French February 2002 PROGRESS REPORT BY UNIT (June 2001 to date) B 10 PART 2 PLANNING, EVALUATION AND TRANSFER 11 SUMMARY OF PET ACTIVTTIES IN 2OO1 _ 2OO2 I - COMMUNITY DIRECTED TREATMENT WITH IVERMECTIN The Community-Directed Treatment with Ivermectin (CDTI) approach is now effective in all the countries where distribution is being carried out. Sierra Leone and Guinea Bissau where CDTI was intemrpted for a number of years due to socio-political unrest have resumed distribution activities since 2001. In Guinea Bissau, these activities are carried out in the fuo Corubal basin following an epidemiological evaluation conducted in June 2001. Treatment is carried out in areas which hitherto were hyper and meso-endemic. In the northern part of the Western extension of the Programme in Guinea, Mali and Senegal, CDTI is the only control method used to control onchocerciasis. In most of the basins under CDTI, the treatment is administered once ayear.In some basins though, the treatment is administered twice ayeff (basins of the Gambia in Senegal, of the Dienkoa and Bougouriba in Burkina Faso, of the Kulpawn-Mole, Lower Black Volta, and Pru in Ghana, of the Oti and its tributaries in Togo, of the Koumongou in Benin, of the Sassandra and N'Zi Bandama in C6te d'Ivoire, of the Baoul6 in Mali, of the Rio Corubal in Guinea Bissau, ...). In order to maximize the perfornance of the field staff, the Programme continues to provide financial and technical assistance to the countries for the training and re-ffaining of district level health personnel, of peripheral health centre nurses in particular, as well as of community distributors (CDDs). The training of the distributors is ensured by the peripheral health centre nurses. Almost all the villages have distributors, who undertake ivermectin dishibution in their respective local communities. With the exception of the health personnel newly transferred to the endemic areas and the newly appointed CDDs, all the workers involved in CDTI, those of the district level in particular, have been trained or retrained in the implementation of CDTI. In 2001, 34 033 community distributors, I 066 health workers including 238 district medical officers and 828 other persons were trained or retrained in CDTI. To date, about 280 doctors, more than 2 600 technicians/nurses and other auxiliary health workers, and more than 55 000 community distributors in villages under CDTI in the Programme area have undergone training or re-training in the various countries. The re-training of health workers is carried out according to the needs identified during supervision. Supervision is more or less regular, depending on the country. Supervision and follow-up on distribution are under the care of the health personnel at the peripheral level, who are also in charge of collecting the data on each village under treatment, and writing a report to the district chief medical officers. [n most of the countries, supervision and follow-up are compromised by insufficient financial and logistical resources. OCP is supporting the countries in these two areas. This supervision also allows investigations into any cases of side effects detected by the CDDs after the treatments. The technicians/nurses are the flrrst responsible to manage any serious side effects reported by the community distributors. NGOs are providing technical, logistical and/or financial assistance for CDTI implementation and in some countries, they participate in the follow-up, supervision and training/re-training of technicians/nurses and community distributors, even in ivermectin distribution. More than 7 million people in 22 000 villages and hamlets were treated with ivermectin using the CDTI approach in 2001. The proportion of villages actually covered as against the number of villages scheduled for treatment in the endemic health districts varies from one country to another. It ranges lvermectin distribution is currently being extended to all the eligible forest in Guinea, Ghana and southern C6te d'Ivoire, where training of community distributors is The progress made in the implementation of CDTI is on the whole sa tory, although there are however, obvious thatsome disparities among countries, or even within the same country. It additional efforts need to be made in order to arrive at a better geographic therapeutic coverage, and Ghana.especially in some countries such as COte d'Ivoire (due to socio-political t2 between 33o/o and l00o/o, with an average above 80 %. The overall average all the countries that effected treatment is about l60/o, with rates fluctu depending on the country. In 2001, villages in the basin of the Bougouri Gambia in Senegal, and of the tributaries of the Oti in Togo where two carried out, a geographic coverage ofabout 90% was achieved. In 2001, all the countries, except Guinea Bissau, ordered the ivermectin from the Mectizan Donation Programme (MDP). The supplies were national systems of drug distribution. Sierra Leone and C6te d'Ivoire ivermectin supplies from MDP in 2001. II . EPIDEMIOLOGICAL EVALUATION Due to the concerted efforts of OCP and the countries, it was possl onchocerciasis epidemiological evaluation teams at the central and levels in each country. The epidemiological evaluations are carried out countries, OCP technicians participate in the evaluations in order to ensure of the national technicians, and to conduct quality control of the evaluations/r therapeutic coverage in between 5lo/o and 85oh, in Burkina Faso, of the s of treatment were they needed directly y received by these and received their first to set up and train (regional and district) these teams. In some training or re-training llance countries themselves, with the assistance of the WHO representations, and integrated into thei In the western and south-eastern extension areas, as well as in the areas of the original Programme area under ivermectin treatment alone or combined with larv make it possible to assess the impact of the activities carried out. iding, these evaluations From January to the present, 590 villages were evaluated in 10 Participating of OCP in botl the original and extension areas, i.e.40 villages in Benin,3l in Burkina F 54 in C6te d'Ivoire, 75 in Ghana, I 14 in Guinea, 37 in Guinea Bissau, 109 in Mali,25 in Niger, 3l in Senegal and 74 in Togo. Some evaluations are still under way in the countries. The standard parasitological method of the skin snip is used to assess the prevalence, the level of infection and possibly the appearance of new infections (i.e. infections that occur in children under five, who did not undergo ivermectin treatment, or individuals who, hitherto, were tested negative during two consecutive evaluations). The large scale evaluation of the Diethylcarbamazine (DEC) patch test also continued in some villages of the Programme area. Epidemiological surveillance in the original Programme area More than 140 sentinel villages located in the original Programme area were evaluated by national teams in 2001 in Benin, Burkina Faso, C6te d'Ivoire, Ghana, Mali, Niger and Togo. The results of these evaluations were generally excellent in most of the basins under epidemiological surveillance. with a prevalence rate of }oh in most of the villages. In the basins that are still under ivermectin treatment, such as those of the Oti/Pendjari and its tributaries, the maximum prevalence rates found rn 13 the villages that were evaluated in 2001 were 3.72Yo in Benin at Porga-village (CMFL 0.21), l}.loh at Moalla (CMFL 0.27) in Ghana and 21 .7o/o at Titira (CMFL 0.90) in Togo. In the basin of the Black Volta in Ghana, the maximum prevalence rate recorded was 14.3%o at Hiampenika (CMFL 0.54). In the villages that were evaluated in 2001 in the original Programme area in Burkina Faso in the Dienkoa basin, which is still under combined ground larviciding and CDTI, the epidemiological situation is excellent with zero prevalence rates in general. No new cases have been reported. Larviciding has ceased in this basin at the end of 2001. In the Bougouriba/Black Volta basin, the highest prevalence rates are 6.6%o at Mouvielo (CMFL 0.24) and 7.9o/o at Salibor (CMFL 0.22). The microfilarial loads are therefore almost nil. In Niger, the epidemiological situation remains excellent. The epidemiological evaluation carried out in 2001 showed zero prevalence rates in the basins of the Diamongou, Niger and Sirba. In the basins of the N'Zi and Black Volta in C6te d'Ivoire, the results are overall satisfactory. The results obtained in l0 villages that were evaluated in March and April 2001 show prevalence rates fluctuating between 0o/o andl.7%o at Namilohokaha (CMFL 0.16) in the N'Zi basin, and0.7%o and, l.7o/o in the Black Volta basin (CMFL0.02 - 0.04). In Ghana, the epidemiological results are excellent, with zero prevalence rates in the villages that were evaluated in the Sissili and Red Volta basin. On the other hand, the epidemiological situation is less satisfactory in the basins of the Black Volta with prevalence rates ranging between 1.5 and 14.3% (CMFL 0 - 0.72), of the Daka with prevalence rates ranging between 13.7% - 15.l% (CMFL 0 - 0.17) and of the Kulpawn/Mole with prevalence rates ranging between 1.51 - 27.5% (CMFL 0.02 - 1.03). However, the trends are clearly on the decline compared to the previous results. Epidemiological evaluation in the extension areas of the Programme In the southem extension in C6te d'Ivoire, the epidemiological evaluations that were carried out in 2001 in the Sassandra basin gave satisfactory results. Prevalence rates, which vary between 0% and 6.3yo, remain low. Microfilarial loads are near zero. On the Comoe and the Marahoue, the results were also good. The same goes for the villages evaluated in the N'Zi and Bandama basins where, however, the villages of Youbouebo (N'Zi) and Gbogbobo (Bandama), had prevalence rates of I 1.8 and 14.7o/o respectively. CMFLs were almost nil. After more than four years of intemrption of ivermectin distribution, an epidemiological evaluation was conducted in June 2001 in Guinea Bissau in the basins of the Rio Geba and Rio Corubal. There was zero prevalence in the l2 villages evaluated in the basin of the Rio Geba. In the basin of the Rio Corubal (25 villages evaluated), prevalence rates were mostly nil or very near 0%o, except in the villages of Cobuncara with a prevalence rate of 35.6% (56.7% in 1990 and 10.8% in 1997) and a CMFL of 2.77, Cuatche with a prevalence rate of 23.6% (22.3% in 1990 and2.2o/o in 1997) and a CMFL of 0.71, Queue with a prevalence rate of 11.8% (57.3% in 1990 and l.7o/o in 1997) and a CMFL of 0.41. Further investigations are under way to better understand this situation. In Guinea, out of the 96 villages that were evaluated between February and August 2001, 76 are located in the basins under both larviciding and ivermectin treatment. The results are fairly satisfactory, and prevalence rates are nil in most of the villages that were evaluated in the basins under larviciding combined with ivermectin treatment, such as rn the Milo-Niandan, Mongo-Kaba, Sankarani l4 and Tinkisso-Bakoye basins. The maximum prevalence recorded in the basin of the Niger in Walia- Dabourou was 15.6% (CMFL 0.48). At Moussoni-Sambouya in the Mafou, prevalence was 60% (CMFL 0.17). At Yalawa, a prevalence of 16.2% and a CMFL of 0.73 were recorded in 1999 (prevalenceof 78.1o/oand CMFL of 42.78 in 1986). Anewevaluationisscheduledtotakeplacein this basin in 2002. At Banfokoro in the basin of the Tinkisso, a prevalence of 7 .3% (CMFL 0.09) was recorded. At Kamakan in the same basin, the prevalence rate which was 50.7o/o in 1987 fell to 0oh in 200 1. In the basins under ivermectin distribution alone in Guinea, the results are excellent in the basins of the Bafing where the maximum prevalence was 3.6 in 9 villages evaluated. The epidemiological situation is also satisfactory in the basin of the Koulountou-Kolilba and Kolente. In Senegal, simple epidemiological evaluations were carried out in April and May 2001 in 31 villages in the basins of the Faleme, the Gambia and the Koila-Kabe, which have been under ivermectin treatment alone since 1988. The results of these epidemiological evaluations remain excellent in all the villages that were evaluated, with prevalence rates varying between |oh and 4.lo/o at Diyala-Bakary in the basin of the Gambia. In the basin of the Faleme, the highest prevalence rates were 3.7Yo at Frandi and3.6%o at Bambadji. They were zero in 20 of the 31 villages that were evaluated. All the infections were found in patients that were more than 20 years old. No new infections were detected in these basins. In the basins of the south-eastern extension in Togo and Benin, which are still under larviciding combined with ivermectin distribution, the epidemiological evaluations that were conducted in 2001 show overall satisfactory epidemiological trends except in a few rare villages. In Benin, prevalence rates of 35.9% (CMFL 2.16) and 22.1% (CMFL 0.72)were recorded in the basin of the Oueme (at Agbogbome and Aguigadji respectively), 19.2%, (CMFL 0.72) in the basin of the Terou/Oueme (at Azraou), 15.9% (CMFL 0.44) in the basin of the Okpara (at Waria). The other villages that were evaluated in the basins of the Okpara, Terou, Adjiro, Zou Agbado, Oli, Koufo show satisfactory epidemiological trends. The basins of the Amou, Anie, Mono, Ogou, Chra, Gban-Houo,Zio and Todje in Togo show generally satisfactory epidemiological trends, except in a few villages: 16.l% (CMFL 0.53) in the basin of the Amou (at lgbo-Amou),l5.7oh (CMFL 0.43) in the basin of the Wawa (at Kemedisso), 16.3olo (CMFL 0.28) at Klo-Mayondi and 14.9% (CMFL 0.20) at Kpime-Seva in the basin of the Todje. These figures, although relatively high, are better than those recorded during the previous evaluations. Ophthalmological Evaluations An ophtalmological evaluation was carried out in November 2000 at Asubende (Ghana) to assess the impact of the combined larviciding and ivermectin control on onchocerciasis induced eye lesions in this focus. The results showed a regression and a stability of the lesions of the anterior and posterior chambers respectively. No ocular microfilariae were found. Some evaluations were carried out in December 2001 in Benin in the basins of the Ou6m6, Okpara and Zou. The analysis of the data is under way. Another evaluation is currently in progress in the basin of the Como6 in C6te d'lvoire. t5 III - BIOSTATISTICS AND INFORMATION SYSTEM The transfer of data-processing tools (equipment, software and data) to the Participating Countries remains a priority for the PET Unit. The Biostatistics and Information Systems (BIS) sub-unit continues to refine the programmes for analysis of the entomo-epidemiological data to be transfened to the countries. In thiJ connection, a workshop was organized from 28 January to l't February 2002, which brought together the computer operators of the Progtamme. BIS also continues to coordinate the processing of entomological and epidemiological evaluation data, namely data input and validation, which are carried out by staff of the technical units and national staff of the countries, and to ensure computer assistance within the Programme (maintenance of the various equipment and progralilnes, local network and related services such as the lnternet and the electronic mail system). This assistance also has to do with computer training, management of the different data banks and their backup. BIS also continues to update the various data banks by supplementing the existing data with information collected on the parasite, the vector and ivermectin treatment. Particular emphasis is placed on the collection and analysis of ivermectin treatment data from 1987 to date. In order to strengthen the operational capacities of the Participating Countries of the Programme in epidemiological data management, each country has been equipped with powerful computer units. The training of national technicians is being accelerated so that they will be able to sort, input, validate and analyse the data collected during the epidemiological evaluations or ivermectin treatments. This data will be reviewed with OCP in order to update the central data bank, the cleaning up of which is still a priority for the Programme. To facilitate the use of the computers in the Participating Countries, the development of a simple and practical programme has been undertaken. This programme allows for the input and consultation of epidemiological and CDTI results at the village, basin and health district levels. It also allows the integrated analysis of epidemiological, entomological and ivermectin treatment data. The use of the Geographical Information System (GIS) is mainly based on the Maplnfo and ArcView software. The HealthMap Unit of WHO in Geneva, in collaboration with OCP, has developed a simple and practical module for the decision makers and technicians of the Participating Countries. This tool allows for integrated spatial analysis of the data collected in connection with onchocerciasis control (epidemiological, entomological and ivermectin treatment). As part of the transfer of skills to the countries, training on this module has been planned and will be intensified for the different national coordinations. Computer-based activities continue to be on the increase within the Programme. The previous local network was extended to include the APOC Programme. A specialized link was installed for the Documentation Centre. Access to Internet (Web, e-mail...) is permanent and accessible to all staff. The training of OCP / APOC staff in Word, PowerPoint, Excel and Internet was intensified in 2001. The staff of the Documentation Centre was trained in the use of a new documentary software (BiblioMaker). In addition to the functions of input and consultation of bibliographical references, this software also allows for the consultation of documents via Internet. IV - TRANSFER OF ACTIVITIES TO THE PARTICIPATING COUNTRIES The transfer of the residual activities of the Programme to the Participating Countries is almost completed and will guarantee their capacity to ensure an effective take over of these activities aftcr l6 2002. The integration of the activities aimed at controlling morbidity, detection and management of recrudescence into the national multidisease epidemiological surveillance systems is in progress. It is fairly advanced in most of the countries but at varying degrees. The training, sensitization of goverrrment authorities and the general public, support to operational research, and transfer to each country of data pertaining to it are being vigorously pursued and should be completed by the end of 2002. For the implementation of these activities, OCP is supported by the WHO Offices in the countries. Contacts between OCP and the Participating Countries have been reinforced; i) on the one hand, through several meetings with the National Coordinators. The annual National Coordinators meeting as organized in the past was replaced in 2001 by more efficient meetings in restricted groups of countries having common problems. Thus the National Coordinators and National Entomologists of Benin, Burkina Faso, Ghana, Niger and Togo met from 12 to 14 March, those of C6te d'lvoire, Guinea and Mali from 18 to 20 April, and those of Guinea Bissau, Senegal and Sierra Leone from 7 to 9 May 2001 in Ouagadougou. Similar meetings have already been planned for 2002 and will start in April. ii) by organizing hands-on training sessions at the Programme's Headquarters for members of the national teams of the different countries; iii) through missions and meetings in the countries which will continue in2002. V. TRAINING In order to guarantee the success of the transfer process, the Programme pursued its training policy by awarding fellowships to the nationals of the Participating Countries for specialization in areas related to onchocerciasis control activities, administration, management of health services and public health. Between September 1999 and February 2002, OCP awarded a total of 69 fellowships (9 of which have already been awarded in 2002). These medium and long-term fellowships are distributed as follows: Epidemiotogy (19), Management of health services (4), Molecular biology (2), Entomology (l l), Public health (32), and General administration (1). This training is part of the training plan that covers the period lggS-2002, which the countries submitted and discussed with the Programme. This brings the number of OCP fellowships to about 580 since the start of the Programme. "On-the-job" training continues in the field in the main areas of onchocerciasis control such as : entomology, methodology of epidemiological evaluation and surveillance, and ivermectin distribution. Special emphasis continues to be laid on the training of National Coordinators and other workers of the national teams in the OCP methodology for the collection of onchocerciasis epidemiological data, the analysis and interpretation of active entomo-epidemiological surveillance data, and on the use of computers. With the exception of Sierra Leone, all the countries have undertaken the training and retraining of agents in the methodology of epidemiological surveillance/evaluation during epidemiological surveys that were carried out in the villages during the past period. Besides the skin snip, the practical aspects of the use of the DEC patch test in the field was emphasized during these training sessions. To date, in total, more than 400 technicians, nurses and other paramedical workers, and more than 60 doctors have been trained in their respective areas of intervention in the countries. The effective use of this staff trained in the context of decentralized epidemiological surveillance/evaluation and integrated into the national multi-disease surveillance system will ensure the effective take over of these activities at all Ievels, especially at the health district, region or intervention area, depending on the country.