West Cameroon NOTF WHO-APOC project final technical report for Mectizan distribution: January, 1st, 2002 - December 31st 2002

!WEST CAMEROON NOTEAMHO-APOC PROIECT GLOBAL 2OOO RIVER BLINDNESS PROGRAM December 2002 2APOC ATO BASED CAPP CBTI CDTI CDDs DMO HA HC HD HKI HQ DS EPI LIST OF ACRONYMS African Program for Onchocerciasis Control Annual Treatment Objec tive BAHAI Agency for Social and Economic Development. French Acronym for Centre d' Approvisionnement Pharmaceutique Provincial. Community Based Treatment with Ivermectin. Community Directed Treatment with Ivermectin Community Directed Distributors. District Medical Officer. Dialogue Structures Expanded Program of Immunization. Global 2000 River Blindness Program. Health Area Health Committee. Health District. Helen Keller International. Head Quarters. GRBP ! IEC Information Education Communication. 3.t IEF IDP IRD KAP LCIF MCH MOH NGDO NOTF OPC PHC POA REA SF SSI TCC WHO International Eye Foundation. Ivermectin Distribution Program. French Acronym for.<, Institut de Recherche et de D6mographie ". Knowledge Aptitude and Perception. Lions Club International Foundation. Maternal and Child Health. Ministry of Health. Non-Governmental Organization for Development. National Onchocerciasis Task Force. Onchocerciasis Project Coordinator. Primary Health Care Plan of Action For Health. Rapid Epidemiological Assessment. Sight First. Sight Savers International. Technical Consultafive Committee World Health Or ganization. 4Follow up on TCC urrles 1) More detailed information regarding REA that was performed. Following the TCC mission to Cameroon, Dr Adrian Hopkins expressed concern that some districts in the province could be at high risk for Loa loa and that West Province should have the full TCC/MEC recorrunandations executed. After consulting with Dr Boussinesq who also expressed the sarne concerry Dr Richards, the Project Staff and I reviewed treatment data to determine whether any of the "at risk Loa communities had attained the requisite 60 % coverage for at least two rounds. Because none of the communities qualified, REA was indicated in each community to establish meso/hyper endemicity before further treatment should continue. The implementation plan was accordingly altered and REA Survey was carried out in 128 communities of which only 8 were found to be hypo endemic. The MOH Provincial Delegate and the District teams expressed their concern that we not withdraw mass treatment from the hypo endemic (6 %) communities because no adverse events had been encountered after four rounds of treatment and treatment was popular in these communities. After lengthy discussion with MEC, NOTF and TCC, Dr Richards obtained finally-ttre approval for continuation of mass treatment in the entire Project zone. 2) Clear description of the measures taken to implement the TCC/MEC recommendations. Full recommendation of MEC/TCC were implemented throughout the project zone. Proper training was given to all tiers of project actors with regards to management of Severe Adverse Reactions. Identified referral hospitals were supplied with appropriate and sufficient equipement / medecine. Post treatment surveillance was established to ensure early detection and prompt referral of cases. Given a few problems of accessibilify experienced last year, it was decided that all subdistrict hospitals would qualify as referral hospitals as well. They were all supplied with appropriate equipment and Medecine for Management of sARs. The staff was properly trained including Lab. Technicians. (14th TCC report) 5The Provincial Chief of Service for Hospital Medicine was in charge of the implementation of TCC/MEC recommendations and was directly supervising the Management of sARs. This was very helpful because, Most of Adverse Reactions were promptly taken care of Adjustments with regards to management of cases occured early because of early supervision of the provincial team. Accordingly we did not have any casualties and most of the expenses remained low even if they were higher at the front end (Training, Supervision and r"*ibilirution-and provision of Equipment and Medecine). The major drawback was the poor quality of Laboratory testing. [n most of the cases the Loa loa micro filaria was identified but the microfilaria load was not determined. We will need longer training period for the Laboratory technicians. a a a 3) Clear indication of the numbers of activities in each district and ensufe that data in all tables are reported consistently. See tables from the final report. 4) An up date of any SAEs that occured during treatment and an explanation of how they are managed. During the 2001 distribution campaign, 5 probable cases of SARs with altered consciousness were encountered. Mr Yanga James was originally from North West Province. Mr Mpempeme Yaya was a native case. Mr Youboudou Sunday was originally from North West Province Mr Batibi Ousseni was originally from Adamaoua Province. Mr Cheeze Isaac was originally from North West Province. These cases came from 3 Health Areas, namely Mata, Manda and Magba, Health Areas, where 3196, 5137 and 8452 persons were treated respectively. Therefore, irrespective of the origins of these cases, we can account for 5 cases out of a total of '1,6 785 persons treated. This represents 2.9 cases for L0 000 treatments. If we consider only native cases (1 out of 5) the ratio falls to 0.59 cases for 10 000. All these cases were treated according to the recofiunended protocole namely IV fluids, Nursing and tube feeding and they have all recovered. I 6Please find below details on each case 7- Mr Batibi Ousseni was a 47 years old male Iiving in Magba for the past 4 years, and originally from Adamaoua province. He took 4 tablets of Mectizan on the 30/08/200L. he stated that a few hours later he developed generalized malaise and entered into a comatose state that night after taken his Mectizan at 8 :00 am. A thick smear revealed the absence of plasmodium falciparum but microfilaria Mansonella ozzardi and Loa loa. (100 mf/rnl) were present. The lumbar puncture revealed 2 mf/d in the LCR. The patient was transferred from Magba subdistrict hospital to intensive care unit in the provincial hospital of Bafoussam because of late referral. He received conventional treatment including IV Fluid, Tube feeding and Nursing. He made a normal recovery and was transferred back to Magba where he was discharged after full recovery. 2- Mr Youboubou Sunday was a 17 years old male who took 3 tablets of Mectizan on the 21,/08/2001. He stated that he had taken 2 previous doses in 1999 and 2000 in school. He related that on the 23/08/2001, he became weak, developed diarrhea and entered into a coma. The thick smear revealed no plasmodium Falciparum but microfilaria Mansonella Perstans and Loa loa (300 *f/.r,I). Patient was given IV Fluid, tube feeding and Nursing. He made an uneventful recovery and was discharged. 3- Mr Yanga James was a 50 years old male living in Njibankoup village in Magba, West Province. He took 4 tablets of Mectizan for the first time on the 24/08/2001 and developed the same evening headaches and subsequently entered into a comatose state about 3 days after treatment. Thick blood film was negative for Plasmodium Falciparum, but positive for Loa loa (140 mflrnl). The patient received conventional treatment including IV Fluid, nasogastric tube feeding and Nursing. The patient had full recovery and was discharged. 4- Mr Cheeze Isaac was a 47 years old male living in Mantele Grand village (Magba)West Province. He took 4 tablets of Mectizan on the 20/08/2001. He is said to have been in perfect health before taking Mectizan. 3 days later he developed generalized muscle pains, back pairy cough and gradually entered into a coma. 7A thick blood film revealed the presence of microfilaria Masonella Perstans and Loa loa (780 mf/rrrl) He was admitted on the 28/08/2001, was given IV fluid, Nasogastric tube feeding and Nursing. He was discharged after full recovery. 5- Mr MpemPeme Yaya was a 35 years old male living in Ngouotou village (Magba). He took 4 tablets of Mectizan on 11,/09/zoo1.The next day on 12/09/2001 he had generalized aches and pains and gradually entered into a coma 2 days after treatment. The tick smear revealed Loa loa 160 mf/ml but nq Plasmodium Falciparum. The CSF revealed 3 mf/rnl as well. The patient was given IV Fluid, Nasogastric tube feeding and Nursing. He was also given Antibiotics for his pulmonary infection. Later on he developed Pressure ulcers at the level of buttocks and heels and was discharged after full recovery. l. ,8 EXECUTIVE SUMMARY The Western Province covers 13870 km2, with an estimated population of about 1, 571' 050 inhabitants. It is devided into 8 administrative divisions, namely Baf.ang, Bangangt€, Mbouda, Foumban, Bandjoun, Mifi and Dschang. These eight administrative units are made of 1,6 Health Districts and 187 Health Areas with it6 Health facilities of which 7'L are private. People living in Western Province are semi- Bantou of mixed races, living between the Bantu of the forest region in the south and the Sudanese of the grass land in the North. That ethnic group ctmprises two tribes : the Bamileke who are larger in number, including people of B#oussam, Bafang, Bangangte, Dschang, Mbouda, Bandjoun districts and the Bamum include p"opl" from sudanic origin and people from Bamileke origin found in Foumban and Foumbot. The distribution of Ivermectin has been established in'the West since 1995 through a five years Lions/Club Sight First funded program, in partnership with the Cameroon Coalition of NGDos and the Ministry of public Heafth. At the end of period, the objectives were not fully reached, which has justified an APOC funding extension. In general, most NGDOs did abide by the development phases of the National plan of Action. SSI did establish an Ivermectin Distribution Program in South West I and South West II. IEF did establish an lvermectin Distribution Program in Adamaoua I and Adamaoua II. HKI did establish an ivermectin Distribution Program in Center I and Center II. BASED has not yet established the second Ivermeitin Distribution Program in Littoral I. Unlike the other NGDOs, The Carter Center decided to launch Ivermectin Distribution in West I and West II projects as a single projec! in order to optimize resources, in spite of the important population involved. Today I feel that the West Province projects are penalized for trying to save time and avoid to raise the administrative burden/cost of the projects. The observations made by APOC Management or by the TCC on West Province Project don't take into account the fact that we are dealing with two initial seperate projects. As you can verify, what is considered to be Western Province Project is one of the most important projects, population wise. We would like you to understand that in fact two projects are involved in West Province and not one. (See National POA in annexe). This should be taken into account when allocating resources. Please allow a second car in Western Province which is made of 2 projects as shown in the National Plan of Actiory to enable efficient monitoring and supervision of the project activities. That need has become urgent now because the two 5 years old Sight First pick up cars have depreciated and their maintenance cost has grown beyong the affordable rate. 9In compliance with CDTI strategy, and taking into account TCC concerns about some areas of high risk with regards to loiasis in which full TCC/MEC recorrunendations should be executed, we felt obliged to alter our field treatment activities.We had decided to phase CDTI activities starting in the seven districts newly classified to be at highest risk for Loa loa. This will concentrate most project activities and surveillance efforts in those districts, and maximize treatment coverage there during the early part of the APOC project. A REA Survey funded by APOC was carried out in these districts to identify these communities not qualified for mass treatment. Accordingly a CDTI implementation plan was disigned to cover all etigible communities in 3 years beginning with the high risk districts for Loa loa. Eventhough, the period covered by this report extends from January 1st to December 31st,,2002, most of our activities have been scheduled between ]anuary and August as shown below : ]anuary 15m and 1,6h,2002 Preparatory meeting of the coordination/ Evaluation meeting. February 6ft and 7ft Coordination meeting at the Provincial level Training of the trainers session. February 14ft and 15h Planning and evaluation meeting with CDTI district teams (phase I and phase II) February 19ft and 20tl..,2002 Planning and evaluation meeting with CBTI district teams (phase III) March 11th _ March 25th REA Survey in communities of Dschang March 18th _ April sth,2002 Training of health district teams (CDTI) March 18tL _ April15h,2002 Retraining session of health district teams.(CBTI) March 22"d - April15h,2002 Procurement of equipment, material and drugs in all the referral hospitals March 25th _ April sth,2002 Training of journalists and radio/TV presenters. t 10 April 16ti' - April 26il,,2002 Sensitization of communities April 29th - May 18h,2002 Selection/Training of CDDS May 2"4 - ]rly 30th,2002 Distribution in CBTI district (phase III) May 23,4 - Iuly 31"t,2002 - Census enumeration - Distribution - Monitoring and supervision in CDTldistricts (phase I and phase II) August 1st - AugpstS'1,st,2002 Reporting and Evaluation. The achievements of the project are the completion of the REA survey in Dschang District and the Census Exercise in Districts of phase I and II as well as the resultin[ optimal coverage rate in these districts. The strenghs of the CDTI implementatioi process include distribution in poorly accessible communities or area with shortage of health personnel at minimal cost, the empowerment of communities, the suppo-rt of the Program by all tiers of the adminiskative structures and good integrafitn of the program activities. Our major challenges were to maintain optimalloverage while expanding our strategy in the remaining districts, known to have u goJa proportion of urban communities. We were concerned also about putting in plice a lound strategy for early identificatiorL prompt referral and good *urrig".rrent of SARs. SECT/ON I : BACKGROI,IND INFORMATION T_he CMRIAIP1 project is located in the Western Province of Cameroory covering 13870 km2, with an estimated population of about L 571,050 inhabitants with a ver! high population density. That figure has slightly decreased though following population enumeration carried out in districts of phase I and II. It is divided in eight administrative divisions made up of sixteen health districts and one hundred and eighty seven health areas. The province is bordered in the West by the North West and South West provinces, in the North by the province of Adamaoua, in the East by the Center Province, and in the South by the Littoral and Center provinces. People living in western province are semi-Bantu of mixed races. The distances between communities are shorter and the roads are good during dry season. The western highlands region is rich in lakes which are of volcanic origin and the soils of this area are the richest in the country for agricultural pourposes. \Alhile the males who are breadwinners leave their families behind in search of areas of greater economic promise, women and children spend most of the day in thefields, kilometers away from homes and return only in the evening. This pittern of 1t activities exPlains why urban Onchocerciasis is found in the Western Province, with higher prevalence in females. This report covers the second year of distribution, from January 1st to December 31't, 2002. All budgeted and approved funds were received on time. CDTI was implemented in 4 more districts this year, namely Batcham, Dschang, Foumban and Mbouda. The five remaining districts will phase into CDTI in 2003. 1) Number of nities in hvper and meso endemic districts. Following the approval of the Western Province CDTI Project in 2000, a three years CDTI transition plan was designed, beginning with the Loa loa high risk districts in 2001, where full TCC/MEC recorunendation were implemented. In 2002, CDTI was implemented in 4 more Districts as stated earlier. Full geographic coverage is going to be reached in 2003. Table L and Graph L show the number of communities in hyper and meso endemic districts and the CDTI transition plan. Table 1 : CDTI Implementation Plan. N" Health Districts #of HA # of endemic communities Population # of CDTI communities Population Involved in CDTI 2001 2002 20f,3 2001 2m.2 2W3 1 Bafang 8 100 5n93 100 57793 2 Bandia 6 57 28322 57 2.8322 3 Bangangte 77 205 69902 205 69902 4 Foumbot 24 201. 9@96 201. 9@96 5 Kekem 6 78 32807 78 32807 6 Malantouen 15 797 67601. 191. 61.607 7 Santchou 5 62 22258 62 22258 8 Batcham 1.2 "107 @290 107 &290 9 Foumban 24 227 96796 221. 96196 10 Mbouda 18 307 144047 307 744047 11 Dschang 2't 1.87 90184 187 90784 t2 Baham 9 71 50163 71 50153 13 Bamendiou 8 51 4f,695 51 4t%95 '1.4 Bandloun 13 l't6 11.ffi9 176 116089 15 Mifi 13 198 228362 198 228362 16 Penka-Michel 13 197 89201 191 89201, TOTAL 212 2i43 "t2960t,6 894 35.3y. 822 38.8% 627 25.9% 368779 22,80'A 394717 43,30y, 532500 33.8% I t2 a Graph 1 CDTI IMPLEMENTATION 2500 2000 # of endemic communities 500 2001 2002 YEARS 2003 Census exercise in these districts revealed a substantial decrease of population figules as compared to estimated. This was also the opportunity to refine the number of communities. The population decrease in Dschang *ur subsequent to the REA results that disqualified several communities for r.,us treatment. See tables 2,3 and 4. T able 2 : Population enumeration District of phase I West Province 2001 Health Dishicb Estimated Population Census Population Population Gap o/to Change Bafang* 9228s 56636 35649 -38,67" Bandja 36745 28322 8423 -22,gYo Bangangte* 11261,4 69902 42712 -37,9% Foumbot* 726865 873/7 39524 -3'1,1% Kekem 37977 31647 6324 -'1,6,6% Malantouen 79661 67601 18060 -22,6% Santchou 21588 22517 -923 4,2% Total 507729 357960 1.49769 -29,4% * Urban Communities l3 Table 3 : Population enumeration Districts of phase II West Province 2002. * Urban Districts Table 4 : Population change 200L-2002 Districts of phase I and II Health Districts Estimated Population Census Population Population Gap o/ Change Bafang 92285 55 636 35 649 -38,6 Bandia 36737 28322 8 423 -22,9 Bangangt6 112614 69 902 42712 -37,9 Batcham 88 8s0 64290 24564 -27,64 Dschang 215 071, 90184 1,24887 - 58,06 Foumban 785 236 96196 89 040 - 8,06 Foumbot 126 865 87 341 39 524 -31,'L K6kem 37 971 3t 647 6324 -'16,6 Malantouen 79 661. 6't 601. 18 060 -?2,6 Mbouda 191 429 1.M047 47 382 -24,75 iantchou 21 s88 22511, 923 + 4,2 fotal 1 188 307 752677 435 642 -36,66 From the outset (1995) the District of Dschang was not qualified for mass treatment because it was identified as being hypo endemic, eventhough not supportive documentation was available. As political pressure was building up, the first REA Survey was carried out in 1998. At that time, 42 communities were selected from 24 Health Areas. These results were grounds for further investigation. In 2002,35 new communities were selected f.rom26 Health Areas. The first Survey was carried out by Drs Oye and Eyamba and the second I a Health Districts Estimated Population Census Population Population Gap o//o Change Batcham 88 8g 64290 24564 - 27.64 Dschang* 215 071 901,U 124887 - 58.06 Foumban* 185 236 96196 89 040 - 48.06 Mbouda* 191,429 744047 47 382 -24.75 Total 680590 394717 285873 -42 t4 survey was carried out by the Executive Secretary personnel, trained by APOC. The surrunary of both survey can be found in tables 5 and 6. Table 5 : REA Survey in Dschang Year Hyper endemic communities Meso endemic communities Hypo endemic communities Total 1998 2 10 30 42 2002 8 5 22 35 Total 10 1.5 52 77 The table below reflects the endemicity level after ajusting the hypo endemic communities by multipling the rate by 1.5. / Table 6 : REA Survey in Dschang after adjustment Year Hyper Meso HyPo Total 1998 2 10 30 42 2002 8 10 17 35 Total 10 20 37 77 It appears that most rural Health Areas are endemic while all urban Health Areas remain hyPo endemic namely Siteu, Fometa, Dombouo and Fokoue. Fiala Foreke Health Area is urban in the North and rural in the South where communities are endemic. Meka'a and Apeng corununities were hypo endemic in 1998 respectively hyper endemic and meso endemic. In 2002, they became As a result 20 communities representing a population of 90184 persons were qualified for mass treatment. The Carter Center entered into a five years agreement in L995 to work in partnership with the Sight First Program, Lions 403 B, and the Ministry of Publii Health tt establish a Community Based Treatment with Ivermectin. The distribution was launched in1996. Until the advent of APOC in 200'1,, communities were receiving Ivermectin through the outreach strategy, which relies on the health center st#f for Mectizan distribution. In this case, the nursing personnel, assisted by Dialogue Structures takes the drug to the villages and distributes it at a minimal cost. l5 The population considered in our project zone is estimated at 1. 296 006. It is a combination of census population in districts of phase I and II and estimated population in the remaining districts (Phase III). 2) Number of villages receiving Ivermectin before and number receiving now. As stated earlier, a 5 years Lions Club/Sight First CBTI funded distribution Program was launched in 1996.It is through that strategy that 267,1089,1,628, 1782, 1845 and 2L45 communities have received treatment respectively in 1996, 1997,19981999,2000 and 2001. Ln2002,2343 communities were treated, of which 171,6 rcceived Ivermectin through CDTI strategy. As you recall, according to our implementation plaru 74|1,y, (171,6 communities) of our endemic communities have transition to CDTI in2002. 3) Number of ti in the received treatment. The communities in the project Area have received treatment 5 times (1996-2000) through a Lions/Sight First funded Community Based Program and two times (2001,-2002) through APOC funded Community Directed Program. Therefore the communities have received treatment seven times since 1996. 4) Community definitiqr A community refers to a group of persons that settle according to cultural and ethnic affirLtty, and that has chosen a place as a central meeting point and has a leader approved by all. Unlike in most project areas where a community corresponds to a village, in the West, given the multiplicity of ethnic groups within a village, quartiers (smaller unit than village) have been used as community. SECTION 2 : IMPLEMENTATTON OF CDTI YEAR II Name : \AIESTERN PROVINCE NOTF/WHO-APOC Date of corunencement of APOC ASSISTANCE : ]ANUARY 2001. The technical report covers the period January 1"t,2002 through December 3'1.st,2002. For the period covered by this report, our objectives were to implement CDTI strategy in eleven out of sixteen districts, which represents 171.6 communities out of a total of 2343, involving 741238 persons out of a total estimated population of 1.296 006. In year III we are planning to expand CDTI to the last five districts, at which time full geographic coverage will be reached. That transition plan was designed to ensure the concentration of most project activities and surveillance effort in at high risk for Loa districts and maximize treatment coverage there during the early part of the APOC project. _!a t6 TRAINING The training session of the Provincial team followed by the Program Review were held at Bana ( Bafang) on February 6m and 7ft, 2002. The atteidees included the Health Delegate, the two Onchocerciasis Project Coordinators, the Carter Center Administrator, the Carter Center Program Officer, the West province project Accountant, the provincial Chief of Service for Drug Procurement and Delivery and the Provincial Chief of Service for Hospital Medecine. The meeting was chair"a Uy the Carter Center Country Representative assisted by the Nationll Onchocerciasis Coordinator. The training was about the CDTI strategy including APOC Administrative and Technical procedures and guidelines. fhat gathering was also an opporfunity to review and evaluate past year activities and to i".o**"rd solutions for identified constraints and weaknesses. Activities to be implemented during the REA exercice in Dschang were identified and resources were assessed. Following the training of the provincial team in Bana, the training of district teams by two members of the standardized training team was held in Bana (Bafang) on February L4m and 1,5th,2002. The training wai about the implemention of thJnewCDJI strategy, with emphasis on APOC Adminsitrative and Technical procedures and guidelines. On the second day, the training was about the management of Severe Adverse Reactions. Tfat gathering provided also an opportunity to identify constraints and achievements of last year treatment period- On February 19ttr and 20\ 2002 retraining session of District teams in CBTI zones was held. The training of journalists and radio/TY presenters was organized in Bafoussam on August 6th,2002. On May 9th, Laboratory Technicians from selected referral hospitals were trained onLoiasis slide preparation and interpretation relative to management of Severe Adverse Reactions. Training of CDDs was scheduled from April 29u to May L8ft, 2OO2 . The places of training and the number of trainees are shown in tables 7 and g. Health Districts # of training undertaken # of TOT trained # of District Staff trained # of Health center staff trained # ofCDDs trained Lab. Techniciaru ATO #of training #of training # of persons Trained ATO # of persons Trained ATO # of persons Trained ATO #ol CDDs ATO # of lab. Technicians Bafang 1.4 20 0 0 4 6 11 32 369 330 2 1 Bandia 8 12 0 0 4 5 7 7 IM 240 1 1 Bangangte 27 49 0 0 5 6 25 33 450 3M 2 2 Foumbot 29 25 0 0 5 5 28 2t3 fi7 336 1 1 Kekem 9 12 0 0 3 5 8 8 151 186 1 1 Malantouen 21. 18 0 0 4 5 20 23 318 u7 2 2 WPHD 2 2 10 10 0 0 0 0 0 0 0 0 Santchou 4 9 0 0 3 4 3 4 86 756 1 1 Batcham 13 79 0 0 5 5 72 13 355 358 1 1 Foumban u 47 0 0 7 7 33 37 740 398 2 2 Mbouda 19 32 0 0 8 9 18 32 765 632 2 2 Dschang 14 21. 0 0 7 6 13 27 475 332 2 2 TOTAL "194 26 10 10 55 63 178 2M 4362 3661. 17 1.6 t7 Table7: Training of different levels of staff in CDTI Districts. (West 2002). *Eventhough Mifi is a CBTI District, it remains the Headquarters of the province and therefore 2 training sessions were undertaken there. Table 8 : Training of CDDs (West 2002) Health Districts Census Population #of Endemic Communities #of Communities Implementing CDTI #of CDDS Trained PoplCDD Ratio Bafang 57947 100 100 330 175 Bandia 28322 57 57 240 118 Bangangte 69902 205 205 346 202 Batcham 64290 1.07 107 358 179 Dschang 90184 187 187 332 271. Foumban 96196 221 221 398 247 Foumbot 962M 201, 201, 336 286 Kekem 32840 78 78 186 776 Malantouen 6160-t 191, 191, 347 177 Mbouda 1.M047 307 307 632 227 Santchou 22258 62 62 '1,56 "142 Total 763831, 17L6 1776 366-1. 208 t8 Table 9 : Retraining of different levels of staff in CBTI Districts (West 2OO2) Health Districb # of training or retralnings undertaken # of physicians trained # of Nurses rehained It of Health Workers Retrained Others Diskict t-evel Area lrvel District Level Area l,evel District level Health Area level ATO* fof Persons Trained ATG {t of Persons Trained ATO #of Persons Trained ATO* #of PeISOnS Trained ATO! #of Persons Trained ATO' #of P€rsons Trained ATO" It of Persons Trained ATO* lof P€rsons Trained Balum 1 1 9 t2 2 2 1 1 3 3 JO x 13 l3 0 0 Bamendiou 1 1 8 8 1 1 0 0 3 3 28 28 9 11 0 0 Bandioun 2 2 13 13 2 2 3 3 ? 3 65 62 t7 t6 0 0 Mifi 1 1 13 13 1 1 5 6 6 6 75 75 11 11 105 105 nurse students Penka-Michel 1 1 13 13 2 2 0 0 4 4 50 4A 18 18 0 0 6 6 55 59 8 8 9 10 19 19 25/1 249 58 69 105 105 nurse studenb TOTAL *Annual Training Objective The training material has been developed but has not yet been harmonized . In the meantime, APOC manuals and tapes have been used for training sessions. Some CDTI materials from previous seminars have been used to introducJthe new concept to local authorities and target corununities. (see table 10) Table 10 : Types of training (CDTI Diskicts) West Province 2001 Type of Training Total trained Type of Material used Facilitation team Major Corutaints Provincial Training 10 Flip charts Posters Manual and writing Materials Standard Training Team District Training 63 Flip charts Posters Manual and writing Materials Provincial and Standard NOTF Training team -Willingness of all districts to implement CDTI the l.st year # of communities involvedHealth Area training 2M Flip charts Posters Manual and writing Materials District teams And standard NOTF Trainilg team -High number of communities involved -Lack of logisitics (motocycles) Communities Training 3661, Posters Treatment books tapes Chalk mensuring rod Health Area Nurse + OPC Logistics Group size l9 These training sessions and meetings provided opportunity to district teams, namely physicians, nurses and health committees to sensitize the local administrative, traditional and political authorities about CDTI strategy. The training sessions were centered on the disease and its public health and socio economic impact, Mectizan distribution, program ownership and community participation, management of adverse reactions, reporting and census. Our Annual Training Objectives in general did take into account past year performance as well as human resources and logistics available at the district level. The ATO was set such as to allow: The training of all disfrict leading teams including at least one district hospital physician. The training of at least 2 nurses per Health Area. The training of at least 1 CDD for 250 persons. In summary 266 training sessions including the provincial session were held troughout the project zone. During these sessions L0 trainers of trainers including the provincial supervisors, 63 districts and 2M health Area staffs were trained. A total number of 3661, CDDs was trained in CDTI districts and they were all selected by their communities. See table L1. Table 11 : Annual Training Objective (West 2002) These CDDs were selected by their communities, they did collect their own drug from the Health Area Health Center, did decide on the mode and time of distribution. ATO # Achieved % Achieved Total # of training undertaken 194 266 137 % Total # of TOT trained 10 10 'I..00'/r Total # of district staff trained 55 63 11,4 % Total # of health area staff trained 178 244 137% Total # of CDDs to be trained 4362 3661, 83.92% 20 Eventhough distribution weeks were decided by the communities, the overall distribution period was decided by the MOH because of reporting deadlines requirements. Communities have used some type of combinatio., brt ihe door by door mode of distribution was preferred. See tablel2. T able 12 : CDTI Implementation plan 2002 Batcham IEC materials were developped and harmonized and were used for sensitization and mobilization sessions throughout the project zone. In additiory Radio spots and specific Prograrns were broadcasted throughout the province. Prior to these activitiesjournalists and Radio/TV presenters were trained by the provincial teams. Mobilization at the community level was aimed at ensuring community involvement with emphasis on their : - Attitude toward and acceptance of the program. - Selection of CDDs by the communities - Timely collection of Mectizan from agreed points. - Decision on motivation of CDDs. - Decision on the mode and time of distribution - Education of communities on the disease and its treatment as well as on its health and socio-economic impact. - Importance of the extended treatment. - Program owership and community participation. Health District #of communities #of communities which selected CDD #of communities which collected drug #of communities whic h decided on method of distribution #of communities that decided on month of dishibution #of communties which trained CDDs #of communities payingCDD Bafang 100 100 100 100 100 100 0 Bandia 57 57 57 57 57 57 0 Bangangte 205 205 205 205 205 205 0 107 't07 107 107 -107 107 0 787 187 187 187 187 187 0 Foumban 221, 22'1, 221 221 221, 22L 0 Foumbot 201, 207 201 201. 201. 207 0 Kekem 78 78 78 78 78 78 0 Malantouen 79'1, 191, 191, 191 191, 19't 0 Mbouda 307 307 307 307 307 307 0 Santchou 62 62 62 62 62 62 0 Total 1716 17L6 171,6 1716 171,6 1716 0 Districts #of endemic communities #of communities mobilized #of communities which received HE about importance of extended treabnent #of Advocacy visits to state director of Health # of MOPH staff involved in mobilization # of NGDO Staff involved In mobilization Bafang 100 100 100 1 38 Bandia 57 57 57 1 12 Bangangte 205 205 205 1 39 Batcham 107 107 107 1, 18 Dschang 187 187 187 1 33 Foumban 221 221. 221. 1, M Foumbot 201. 201, 201, 1 33 Kekem 78 78 78 1 13 Mifi 10 5 Malantouen 191 791 1.91 1 28 Mbouda 307 307 307 41 Santchou 62 62 62 1 8 Total 171,6 1716 1716 11, 317 5 2l Table L3 : Mobilization and sensitization of target CDTI communities The mobilization and IEC activities in the endemic communities were best achieved through the involvement of administrative and traditional authorities, focus groups, outreach by Public Health Nurses and radio spots and programs to the communities. The mobilization efforts were encouraging, especially the involvement of traditional and political authorities, which continues to bring about positive attitudes and acceptance toward the program. In fact regardless of our CDTI implementation plan, all Health District and communities throughout the project area, were eager to implement CDTI this year. This reflects a good response of the corrrrnunity to the new aPProach. mobilization of To further improve mobilization of target communities there is a : Need for more flyers and brochures targeted at local authorities and opinion leaders. Our Objective for the coming Campaign is to provide one IEC kit to each health unit. es I Need to increase awareness by having an onchocerciasis week with schools involvement. 22 - Need for most appropriate communication channels and strategy, namely griots, storytellers, religious leaders and community association groups. - Need for more Governement Committment by allocating resources for Onchocerciasis week and counter financing for onchoceriiasis activities. - Need for finaTization and testing of IEC material on sARs. SECTION 3: ACHIEWMENTS For the first time, mass treatment was begun in Dschang following the identification of endemic communities in 26u\, Health Areas. Training on CDTI implementation was carried out at the provincial, Distric! Health Area and community levels and we had good achievement rates for most of our Annual Objectives. After their selectton,366'1. CDDs were trained in171.6 endemic communities and they all performed well. Thuy are ready to continue with the program but expect higher motivation. Census exercises were undertaken in Districts of phase I and phase II and have helped to refine our population figures and community numblrs. Successful implementation of our CDTI transition plan with optimal therapeutic and geographic coverage in both rural and urban communities. A total of 629 906 persons were treated in 114 400 households and 17-1,6 communities, out of a total census population of 763 831 persons in CDTI Districts. This represents a coverage rate of 825 % of total population and g3.g % of our ATo . The district of Foumbot has a higher than expected therapeutic coverage rate (89.1,%). This might be due to the fact that Foumbot is not only in Internationlal Market, but also Foumbot has the most fertile lands in the Western Province. This leads to a migration bias, attracting essentially adult population, registered most of the time as resident so they won't miss their treatment . (Se" table 14)- 23 Table 14 : Treatment Activities CDTI Districts (West Province 2002) In the meantime, 270 867 persons were treated in CBTI Districts out of an estimated population of 532 510 persons. This represents 82.5% of our ATO and 50.8 o/o of. total population. Beside the fact that this project Area is still under CBTI strategy, we believe that the major reason for that low coverage is the over estimation of the population figure as noted in phase I and II. We are confident that following the population enumeration the therapeutic coverage will be optimal. (See table 15). Table 15 : Treatment Activities CBTI Districts - West Province 2002 + Health Districts Census Population ATO Persons Treated Therapeutic coverage Communities to be treated Communities Treated ollo ATO Total Population Bafang 57 947 60 000 47 780 79,6 82,7 100 100 100 Bandia 28322 27 000 23932 88,6 U,5 57 57 100 Bangangt6 69902 70 000 59 829 85,4 85,6 20s 205 100 Batcham u290 65 000 49758 76,5 77,4 1,07 107 100 Dschang 90 1U 70249 76 81,4 '/.09,3 85,1 '1,87 187 100 Foumban 96196 8s 000 81 910 96,3 85,1 221, 221 100 Foumbot 962M 80 000 85 593 106,9 89,1 201 201, 100 Kekem 32840 28 000 24590 87,8 80 78 78 100 Malantouen 61.601 46 000 47998 9'1,,3 68,2 191 191 100 Mbouda 'tMM7 120 000 779 410 99,5 82,9 307 307 100 iantchou 22258 20 000 18292 9'1,,46 82,2 62 62 100 Total 763837 67't 249 629 906 93,8 82,5 1776 17't6 100 Health Districts Estimated Population ATO Persons Treated Therapeutic coverage Communities to be traited Communties Treated o/lo ATO Estimated Population Baham 50 163 35 000 30 676 87,6 61,2 7'1, 7't 100 Bamendiou 48 69s 35 000 25 521 72,9 52,4 51 51 100 Bandioun 1'1.6089 7s 000 58 807 78,4 50,7 116 1L6 100 Mifi 228362 130 000 L04289 80,2 45,7 198 198 100 Penka Michel 89207 53 1& 51,574 97 57,8 191 191 100 Iotal 532 510 328754 270 867 82,5 50,8 627 627 100 a 24 t a a- In summary, a total of 900 773 persons were treated in 2343 endemic communities out of an Annual Treatment Objective of 1 000 042, which represents a therapeutic coverage rate of 90.7 % of our ATO and 69.50 % of our total population. In addition, 20 876 Persons were treated passively in Dschang which leads to a total treatment of 921649 persons in the West Province. See table 16. Table 16 : West Province GRBP - Assited Treatment2}l2 *Census population * CDTI Districts and s on Monitoring and supervision were scheduled from May 23,d to August gL"t, 2002. These activities have occured in cascade, the provincial team have iupervised the district teams which in turn have supervised the health area level. CDDs activities have been supervised primarily by the health area team, eventhough district and provincial teams have monitored/supervised from time to time the community activities. In general these supervisions occured during training, sensitization/ mobilization and distribution. The supervisions occured during training and sensitization to ensure the quality control and to resolve eventuel problems encountered. a HEALTH DXSTRrcT POPULATION ESTIMATE ATO f OF PERSONS TREATED COVERAGE #oF COMMUNITIES ATO foF COMMUNTTIES TREATED COVERAGE Bafang * 57 793" 60 000 47 780 82,7'A 100 100 100 10070 Baham 50 163 3s 000 30676 61,,2o/o 7"1 7"t 77 700% Bamendiou 48 695 3s 000 ?5527 52,4% 51 51 51 700% Bandia * 28322: 27m0 2i932 84,5oA 57 57 57 100% ilandloun 116089 75W0 58 807 il,70/o 116 11.6 l"t6 1007o Bangangte n 69902* 70 000 59 829 85,6.4 205 205 205 700% Batcham * @29o" 65 000 49758 77,4"/o 707 107 707 7W% Dschanq tr 90 184* 70249 768't4 85,1.'A 787 1.87 187 100% Foumban * 96196* 85 000 81 910 85,7'A 221 221. 221 1007o Foumbot H 96096" 80 000 8s s93 89,'t"/, 201 201 207 100OA Kekem * 32807* 28 639 24590 80,o% 78 78 78 7m% Malatouen * 6',,. @7* 116 000 4799g 68,z',A 791. 191 791 -1,0070 Mbouda tr -1.44M7" 120 m0 7t9 470 82,9o/o 307 307 307 100% Mifi )78362 130 000 7M289 45,7"A 198 198 198 100o/o Penka-Michel 89 201. 53 1g 51.574 57,8% 191 197 191. T00OA Santchou * 22258" 20 000 18292 82,2'A 62 62 62 100% Total 1 296006 1 000 042 900773 69,5./" 2343 2i43 2i43 lffiy. 25 The following are activities carried out during supervision : - Ensuring that the population enumeration is done properly. - Ensuring that treatment books and Mectizan logs are up to par. - Ensuring that the correct dose of Mectizan is given and that only eligible population is treated. - Ensuring that Adverse Reactions are managed properly. - Ensuring that Mectizan tablets are kept and dispensed properly and that they are secured. - Monitoring the coverage rates. - Ensuring good data quality. To minimize tablet wastage and ensure regular CDD supervision, a limited number of tablets was given to CDDs so they had to come back on a regular basis to get more tablets. This was a good opportunity to supervise the CDDs work. Supervision occured within communities as well. The Health Area nurses took that opportunig to check agreed procedures and messages given to the community members. Higher level supervision was more concerned with sensitization, training and utilization of Program management tools, namely the Mectizan Inventory Forms. One of the Structures involved in supervision process was the Foundation MOJE, a National NGDO. The Foundation MOJE was involved in all field activities, including training of trainers, training of District and Health Area teams as well as training of CDDs. The NGDO representative is a member of District and Health Area mobilization teams and is engaged in treatment of several communities in his Health Area. Foundation MOJE has been responsible for the treatment of a selected zone in the Health District of Mifi. SECZON 4 : STRENGITTS OF THE CDTI IMPLEMENTATION PROCESS Poorly accessible communities or areas with shortage of health personnel have been receiving Mectizan treatment and other health prograrns. Communities have been taking full responsibility so far by selecting their own distributors, by collecting drug, by deciding on the mode and time of distribution. They are eager be fully involved in the process. Good achievement rates have been noticed in CDTI Districts The empowerment of communities through the CDTI process and capacity building has strenghened local structures, rendering them more functional. a t ,t I I 26 t a P Local traditional, political and administrative authorities have already expressed their support of the new strategy, by attending most of the mobilization meetings. All Primary Health Care personnel have been trained on the CDTI strategy and are fully involved in the training of CDDs. The health facilities are used as collection points at health area level. There is a good potential for the integration of the program, including Mectizan distribution within Primary Health care system. Weaknesses of the CDTI implementation process. The worrying laborious early CDTI implementation process with subsequent administrative burden and increased work load for NGDO and MopH personnel. Poor data quality and inconsistencies may be increased as a result of irregular supervision of CDDs activities. High CDDs training cost with subsequent adjustement of group size during CDD training sessions. Implementation of CDTI strategy in Urban Communities. su ort needed a) From Government lncreased counter-part funding Involvement at the highest level for full mobilization of all tiers of government. Multisectorial approach for community sensitization and mobilization Ensure that project vehicules and equipment are used mainly for the intended Purpose. b) From APOC - Ensure that approved funds will continue to be released on a timely basis. - Continue to minimize unplanned activities . - Continue to bring full support to the Executive Secretary. - Continue to assist the program in refining the implementation of CDTI in urban communities. c) From communities - Communities should be more active and should decide on locally appropriate compensatory mechanisms for CDDs. Besides community involvement as a group, there should be more personal I lf involvement to CDTI activities.