.,J/ ? REoruatCIJ B ls, #fl. WORLD IJEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE ,rrfi, Onchocerciasis Control Programme in West Africa Programme de Lutte contre l'Onchocercose en Afrique de l'Ouest REPORT OF THE EVALUATION OF THE TVERMECTIN DISTRIBI,ITION IN FOUR COUNTRIES (COTE D'IVOIRE, BENIN, TOGO AND GHANA) By (Prot R. B. Biritwum, Dr. M. Sylla, Dr. T. Diarra) (Dr. J. Amankwa, Dr. G. P. Brika, Dr. L. A. Assogba and Dr. M. O. Traore) Ouagadougou, le 4 Ir{ai 1996 ,,0 ./ t5 '['rrtrlc ol C'tirrtcrtts I Acknrlrvlctlqcrnettt (i) Z. In troductio n 1 3. Objectives 2 4. Methoclology 3 5. Coverage of individuals with ivermectin treatment in the selected villages. 6 6. Ivermectin treatment Coverage of individuals and villages 8 1. Frequenry of ivermectin treatment. I U. Reasons for not taking the ivermectin tablets during the last treatment 9. Reactions follorving the last ivermectin administrati<ln. 13 10 The preferred method of ivermectin distribution, existence of trained volunteers and the assessment of community support during the administration of the tablets. 14 11. General operation of the team in the villages during treatment. 15 RESULTS OF INTERVIEWS WITH NATIONAL HEALTH OFFICIAI.^S, NATIONAL ONCHOCERCIASIS PROGRAMME COORDINATORS AND OTHER HEALTH AND EDUCATION OtrFICERS IN THE COUNTRIES. 12 13 14 1-5 16 I] How to increase the participation of the community in the Programme. Plans for staff training at all levels Supervision and Surveillance. Supply and deliverv Discussions rvith National Coordinators. DiscLrssions rvitlt local lrelrlth ollicials ancl teachers. Di.scussion Recomntetttllttiort LIS'[ OF ANNt:XUS 16 16 16 16 t7 1l rtt ?0 2t t1 rti l9 I 3,\c k tto r. lctl ge rrtcrr I 'l'hc tearn would like ro th:rnk the Dircctor of the OCI'] ancl the staff at all levels for the excellent support and the cfficient organization provided to accomplish such a challenging iisf. within the schecluled [erio6. Special thanks to staff of PET in particuiar, the statistics unit for technical support. National representatives in all countries assiste<J the team in many ways and we would like to express our appreciation' Our thanks go to the various communiiies who provided us with the traditional welcome and hospitality. 1Introduction The OCP has adopted the large scale administration of ivermectin as one of the strategies for onchocerciasis control in the programme areas. This is particularly aimed at reducing the morbidiry from onchocerciasis i.e. eye diseases and blindness. In this respect, the current strategy is to aim ivermectin treatment at all 'at risk' populations. The target population includes all people living in onchocercae endemic areas. Full scale ivermectin distribution in most of the Programme extension areas started in 1990. In 1995, ivermectin treatment evaluation was conducted in three of the countries, Mali, Senegal and Guinea. One of the recommendations of the team was to continue the evaluation in the rest of the countries. This was accepted by the expert advisory committee at its 17'h session in 1995, and the present study is the result of the recommendation. The new African Programme for Onchocerciasis Control (APOC) has begun and experiences and results of the evaluation exercises are expected to be useful to the new programme. It is important for the existing Onchocerciasis programme which has been scheduled to end by the year 2002, to support the new programme with vital information. Background i nformation. In the countries for the evaluation, ivermectin distribution started at a low level in 1987 in Ghana with the first country trial. Since then the distribution has been introduced gradually to involve as many basins as possible and has now been firmly established since 1992 in all the programme countries. AboLrt 11,000 villages have been covered and over 2two million individuals treated in all the countries. In Benin, there are 72 main river basins mostly in the extension zones. These have been grouped into 8 zones. The distribution in cote d'Ivoire has been carried out in five basins in the extension areas and2 basins in the original programme areas. In Ghana, the basins that are involved in the distribution are four in the extension areas and 4 in the initial programme areas. The distribution in Togo has been carried out within 7 zones made up of 18 basins. The four countries for the evaluation form part of the original programme countries. The original areas within each country scheduled for control had to be extended in order to protect the original area from re-invasion and infiltration of infected flies from the areas not under control. Objectives of the study 1. To evaluate the ivermectin delivery programme in four countries, Cote d' Ivoire, Benin, Togo and Ghana. Z. To advice the Programme in the light of the findings of the evaluation Special attention was to be paid to the coverage of the individuals in the villages, the .) coverage <ll villages in the trasilts ancl to tlrc nranagenrent <ti thc treatnlent prograrnmcs within the countries and the preparation tqwards the decentralization of the Programme. 4NIE]'I IODOLOGY 'l-he cvulurrtion oI ivermectin treatnlent of OCP in this study covered four countries, [: Core D' Ivoire, lJenin, Togo and Ghana. Nine villages were randomly selected in each counrn'ftlr the evaluation as first choice villages, in addition nine othervillageswere also nrnclonrlv chosen as alternate. In each oI the countries, three first choice villages and tlrrec ulrcrnate villages for each of the three selected basins were selected taking into rrccoLrnr, tlre distances of villages fr<lnr the operating headquarters in the particular counln' [-Jerrveerr 20 and 25 families were to be intervierved in each village to give a sample size ril uirorrr i80 in each basin. Where the village rvas small, all the families were to be inren,icrvecl. A family questionnaire rvas administered to all the members present in the sclccrctl lamily. A village questionnaire rvas administered to each village chief or his rcp rcse n tl t ive. 'l-lrc strrtlv surrtecl in each country rvith a discussion with a representative of the Ministry oi Ilclrlrh uncl an intervicrv with the National Onchocerciasis Programme Coordinator usirrq rr srnrctured questionnaire. At the local level, teachers and health officials were also inrcn,ievu,ed regarding the distribution of the ivermectin tablets again using a list of r<tpics irlr cliscussion. The research instruments and the list of indicators can be seen in the list oI annexes. Tiie evaluation teanl consisted of a consultant sociologist, a consultant epidemiologist, 5a s(a[[ of OCP and one National Onchocerciasis Coordinator not [r<;m the same country. Two local interviewers were hired to assist in the interpretation of the questionnaire. The same merhodology was useci in all the four countries. All the completed questionnaires were reviewed at the end of each day. A debriefing with the assessment team was held after each countries exercise. Where the first choice was not treated, the second choice village was assessed. The list of the actual villages used in the study is reported in the results and also in figures 7 and 8. 6Ii.I.:St-Jt-.I'S OF 1-IIE INI-EITVIE\VS \VITII 'I'IIE INI)IVIDUAL^S AND THE, VILLAGE CI IllrFS ANALYSIS OF Irr\lv'l I LY QUESTIONNAIRE 'l'a5le l. Percentage of incliviclrrals treated during the last iverrnectin treatment pe riod. (in the selected villages) Coycrage of individuals rvitlr ivcrrnectin treatlncnt in the selected villages T:rllle l. <Jescrihes the over all pcrcentage of inclividuals treated in each country during tlrc [;.rst treatment round. For the total sample interviewed,67.ZVo had received ivernretin treatment. Cote d' Ivoire ancl Glrana had about 'lOVo covetage and Benin and COUNTRY TREATED TOTAL Vo BENIN 625 974 64.2 GHANA 620 866 7t.6 COTE D' IVOIRE 548 761 72.0 TOGO 509 TO'TAL ?303 824 61.8 3425 61.2 1Togo had around600/o.'['hc resrrlts of each oIthe se lcctcd villages can be secn in t:tblcs 7 and 8 (annexes l and 2'y. ln particular, it appears tltat more males received treatment than females in most of the villages even taking into consideration, the tact that sorne women do not take the tablets on account of pregnanry. (r) rI] o sJ o tr.lf- IJ rrlJ UJa s r-o\ c1 .Oq) q[nr- q c) o\ cfl co@ \ o\ oi\o .+ o o o\ O\o o oo a cr1 co @ e.i .+ J F oF N \o I @ N N m oN o c- \o \o EIF t!dFQ lr) \o o o ri \o @ \o f- \n (r) ? o z oz xQo\ (n c.lr- n oo\o N o!f, ao +\o -t o\\o o? rn oO q rnf- ol O.\o oq ca,f- q r-r\ o\ ..t? \o oo J F oF \o rn ce o\ .+ o\O. Nco(n r- ca r- 6l \o\nN o\o c.l \n\f, o\\o$ \o R O. IJ.]F tr) F @(n c.l r- co(\{ @ r N ONN [n co N o\ o\tf,N F.o F{ \o c.1 \n$ c.) z V) V F V) I!) o V =V (!) U) tllJ o z z J v D c0 ru o =z oO r! D o & 2 i<{a o z m o m z o z F o &V >.dFzp B z z rl] la z o IJ] 5 =h Fl oU o o oF cc Z?a6z :.3ao a: rI] F9- Z- -/'tXri> F< a lJ) s-t troF1z =Ho>zd < g.) ,44 _\ (,)<OJ =- Z l& o tLl o Fz rI] C) u.l O. a rrl zZ o F(n r'\ 3 C J z o \5 - U) U) J z oi o ,.o a!F
10 Ivcrmectin treatment Coverage of individuals and villages Tzrble 2 shows the results of individuals and villages treated by basin. With respect to indiviciual coverage, all the three basins in Cote d' Ivoire and Ghana had satisfactory coverage (about 70Vo), where as in Togo and in Benin, one out of the three basins had poor coverage betwe en 20Vo and 4OVo. Concerning the coverage of villages within the basins, Comoe artd Bou Bandama in Cote D' Ivoire had poor village coverage and Kara in Togo also had poor coverage. ll ANALYSIS OF FAMILY QUESTIONNAIRE Table 3 Percentage of individuals who have received the expected number of treatments for the respective village Frequency of ivermectin treatment. Table 3 describes the proportion of individuals according to whether or not the individual had received treatment during all the treatment rounds for his or her respective village. [n all the sample,2(>.lo/o had never received treatment whilst 29.4Vo had received all the expected treatment. Again, Benin and Togo had similar low results. About a third had never received treatment and almost half had received partial rrearment. With respect to Cote D' Ivoire, 42.2Vo had received complete treatment. In the case o[Ghana, the figures were 76.4Vonever received treatment, S3.9Vopartial and 29.7 complete. COUNTRY TOTAL NUMBER OF INDIVIDUAL S NEVER TREATE D PARTIAL TREATMENT COMPLETE ALL TREATMEN T BENIN 914 30.1 43.4 26.5 GHANA 866 16.4 53.9 29.7 COTE D' IVOIRE 16r 23.6 33.8 42.4 TOGO 824 33.7 45.6 20.6 *zgH HS cq ce c-l CN ON 9\.c o.l c.l <l ooc.l EI o F& o (a \o o\ o rI] U) D tJ. i4d t ca @ 9 9N ila rrl Irl :-.tooaz4upo q @ q $ tr) c') @ \q \o Uz z o r!& O. q t t-: r- ,.rl r-. vl ce 9tr) Fz E](r) ca c.') C., .d, \c) $ o.l st-- cl t/) .1- vl .f, n Nol JrlJ<FFFO<oztaFd F o\$ ca -J c.l ca c..l v-) ca &Fz O z z rLl z c r-L,) (, b t.i-.it- (, o F J F F c-l q) E o a () a.) E q) (h o oo q.) a,) oo q) -o L U) thd() + O :-- r! ?Zz Fa ttlf, o J /-) U) a J z 13 I{easons for not taking thc ivernrectin tablets during the last treatnlent The most frequent reason for not receiving the ivermectin treatment during the last treatment period was absence from the village (Table 4), between 43.3Vo in Benin and 74.2o/o in Cote D' Ivoire. Pregnancy was given as the reason in 5.6Vo of those who had not received the treatment during the last treatment round. The other reasons included under age or too old in 6.6Vo,2.6Vo of the individual actually refused to take the tablets, 7.9Vowas on account of shortage of the tablets and a large proportion did not take the tablets for other reasons. The other reasons included for example sickness, lack of information about the date of treatment and because their names were not in the register (health official refused to update the register). In other situations some individuals were refused because the husband or the mother was not present, also the appointed date was not convenient to the inhabitants, i.e. market days. I IIJ] rrr F tr) ,ra) $. o\ 2. CI s.)O4 @ 9 nN c! a lr} \f,. c--) .') ca co N N o c-) o N c\l \f z O. co Gl .+ oq O. oz UF 9 co (") o N \t? c.I 9@ H rr)886ag z o.co co co q ca o\ -q r-r- c'l lat oo o r!F trl F Fz OO r/)N\o N\o covtr) o\ tr) mO co GI z z ul z tr.l 5 o LI]F U oF J F oF I q) E () L U) o t) t< c)() 1r tr () q) E () bo v L o U) o () a) L 0) () (,) q.) oo (,)(J L o tr) c..) _c IJ.) zz F rJ) Ixf, O J 2 (l. 2a J z I1.5 Reactiolrs follon'ing the last ivermectin administration. Table 5 represents the reaction after taking ivermectin. In general more than 85Vo of the people had no reaction or felt better. The most common side effect was itching (5.6%o) followed by pain (l.9Vo\, rash (7.8Vo), oedema (1.LVo) and the others constituted (0.eVo). t 16 ANALYSIS OF VILLAGE QUESTIONNAIRE Table 6. SUMMARY OF THE ANALYSIS OF ALL THE VILLAGES VTSITED Thc prefcrred method of ivermectin distribution, existence of trained volunteers and the assessnrent of community support during the administration o[ the tablets. A roral of 130 villages rvere visited by the evaluation team, 97 Qa,6Vo) had received trearrnent. The results of the responses o[ the chief of each village or its representative can bc seen in table 6, concerning (i) the preferred method of ivermectin distribution, (ii) the exisrence of tr:rined volunteers and (iii) participation of the community in the clistribution of the ivermectin tablets. Ghana and Cote D'Ivoire seem to prefer mobile rvhilst the situation is ambivalent in Togo and Benin. With resPect to trained volunteers, very few existed in the villages interviewed except for Ghana where 13 out of 31 villages (1 1.9o/o) have trained volunteers. COUNTRY PREFERRED METHOD TRAINED VOLUNTEERS IN VILI.AGE PARTICIPATION IN THE DISTRIBUTION MOB. COM YES NO YES NO BENIN 11 10 3 18 14 7 GI-IANA 25 6 13 18 )) 9 COTE D'IVOIRE 28 ) 2 28 18 t2 TOGO 1 8 6 9 15 0 .I-OTAL l1 26 24 83 69 28 f l1 In most villages, some voluntecrs participated in the distribution <ll the ivernlectin talllets by mobiliz-ation of the comnrunity, calling out names from the register, weighing and itlso keeping tablets for those absent at the time of the distribution. General operation of the team in the villages during treatment In all the instances, weighing scales or height measuring instruments were used in determining the dose of the treatment. The tablets were swallowed in the presence of the team except in few instances where there was no water at the table and in one village the date happened to be during the fast of the moslems and the tables had to be taken later. The few problems reported included shortage of tablets, the fact that the team refused to leave the tablets for absent individuals at the nearest health centre. The community's knowledge about the duration of ivermectin treatment was assessed, horvever, nobody had knorvledge of how long they were to take the tablets, though they knerv tire periodicity. The time spent in the most of the villages seemed adequate for the size of the population. However, in other villages the time appeared too short refer to annex 5. Almost everybocly was able to identify the ivermectin tablets and everybody was willing to take the tablet during the next treatment. 18 R ES LJ LTS OF INTERVIEWS WITH NATIONAL HEALTH OFFICIATS, NATIONAL ONCI{OCERCIASIS PROGRAMME COORDINATORS AND OTHER HEALTH AND EDUCATION OFFICERS IN THE COUNTRIES. How to increase the participation of the community in the Programme In all the countries, the responses were similar, that is to use the network of the Primary Health Workers and the system as envisaged in the Bamako Initiative. Plans for staff training at all levels In Cote d' Ivoire, the government is in the process of planning the training according to the minimum package of activities. In Benin, some workers have been trained but not at the peripheral levels. In Togo, the national team has been trained but very little training of the peripheral level staff has been done. The same can be said about Ghana rvhere Regional and some District Medical Officers have been trained. Supen'ision and Surveillance. Almost all countries plan to integrate Onchocerciasis surveillance with the existing clisease surveillance system. This will be done through education on method of diagnosis and case definition. Suppll' and delivery Ivermectin will be included in the essential drug list for all the countries and distributed freeh, through the existing system. 19 Discussions with National Coordinators. Only two coordinators had elaborate plan for Onchocerciasis control other than the one from OCP. The plans had been prepared to use funds from local WHO resources mostly for surveillance and education. The main complaint by the National Coordinators was the lack of physical feed back on data sent to OCP. This was considered to be a handicap in not being able to assess whether the coordinator was doing well or not. Discussions with local health offrcials and teachers. All the staff interviewed in all the countries complained that they had not been adequately involved in the distribution of ivermectin and they showed willingness to participate. 20 Discussion The team visited 130 villages and interviewed3,425 individuals in all the 4 countries, Cote D' Ivoire, Benin, Togo and Ghana. In general, the overall coverage of all the four countries of 67.ZVo appear to be satisfactory. Togo and Benin however, had coverage below the acceptable minimum level of 65%. In these two countries, one out of the three selected basins was poorly treated. Despite the general good results of Cote D' Ivoire, Comoe basin was also poorly treated. Regarding the frequency of treatment, there is a high percentage of people who have never received ivermectin tablet in the treated villages for all the four countries (26,L7o), more so in Benin, Togo and Cote D' Ivoire. This is very serious observation in view of the number of times each country has been treated. The main reasons of not taking the tablets was absence from the village, other reasons given included refusal by the team on account of names not in the register, absence of husband or mother. Some individuals mentioned lack of information regarding the date of treatment and information on the reasons for the treatment. Poor accessibility could be some of the reason and unwillingness on the part of certain inhabitants of other villages to assemble in the next selected village for treatment. These reasons should form the basis to improve on the operation of the distribution of the iabtets. It is important to note that at least 20Vo in all the countries had taken ali the expected treatments. It is also important to note for the purposes of improving the health education component of the programme, that 2.6Vo had refused to take the tablets. Z 22 Regarcling the side effects of the tablets, it can be stated that the tablet was well tolerarecJ by all. Only 1.47o haci some complaints and in these circumstances, itwas not necessary to take any action. The response to the programme was very encouraging, in all the treated villages all the inlrabirants ancl their chiefs were enthusiastic to take the tablets in the next treatment rou ncl. 1-he pre[erred method for ivermectin distribution suggested by most villages was mobile distrilrrrtion 7l (73.2o/o) out ol 97 villages. Several reasons were given for this chclice, lack ol ntoney to pay any volunteer should he or she request payment after some time, possible dishonesty in selling the cJrugs to other people, lack of confidence in the Iocal \,olunreer and the opportunity to interact with health officials who might solve other health issues. The fairness of the health team was also mentioned. It is believed that rvith good education and efficient organization, the communities could be encouraged to accept communiry distribution. \\/ith respect to trained volunteers, only few existed in the villages. The analysis showed f:rirl1' good community participation during the treatment. C6nccrning the interviews with National health officials, there was a strong impression oi the countries readiness to take over the activities of the Onchocerciasis programme. Hor,r,ever, tfie local health officials an<J local teachers have not yet been adequately involved in the distribution of ivermectin. 23 24 ITI'CONINIENDATION 'l'here is a need to agree with National Coordinators on the expected geographical coverage and the policy for treatment. 2. Flcalth eclucation will be needed to reduce further, the percentage of people who refuse to take tlte ivermectirt tablets ,1 Cornrnunit),treatrnent may he a viable alternative after good education and cxposu re [.ocal health organization must be involved in the planning and implementation and the supervision of the distribution of ivermectin tablets. 1 125 List of annexes lvlaps of the villages visited in each country. List of indicators Questionnaires and interview schedules Other detailed analysis on family questionnaires Line list of data on the village questionnaires A report on field experiences (Dr. Diarra's summary) Names of all Computer files including databases on the study to be lodged with the statistics unit of PET. l-ocation of the field forms. List of people seen during the survey. 2. J. 4. 5. 6. 7. 8 9 76 ANNEX 1 ANALYSIS OF FAMILY QUESTIONNAIRE Table 7. Percentage of indivicluals treated by village COUNTR Y BASIN VILLAGE TREATED TOTAL ?o BE,NIN OKPARA MOUMOUDJI i04 125 83.2 ATCI{AKPA 101 176 57.4 AGBOGON 53 55 96.4 SOTA ZOUGOU t42 164 86.6 KABEKA 72 82 87.8 GBEKOU 13 173 42.2 OUEMA SAMIONDJI 31 55 s6.4 AT-I'ANKPE t DOVI-LEGBA 49 144 34.0 GHANA ASSUKWAKW A LARBOANO 86 119 72.3 MUSA AKURA 38 51 74.5 DODO AMAN 91 162 56.2 KULPAWN /MOLE SOMA 12 110 o5.5 BIDIMA 42 10 60.0 KATOA 106 r37 77.4 BUI BUI CAMP 105 114 92.t JENSOSO a MATUKWA 80 103 77.7 2l ANALYSIS OF FAMILY QUESTIONNAIRE Table 7 cont. Percentage of individuals treated by village COUNTR Y BASIN VILLAGE TREATED TOTA L ?o COTE D'IVOIRE COMOE AHININKRO 69 91 75.8 ETHIEN-K a 74.5AMANGOUAKR o 123 165 MARAHOUE GOATIFTA 68 123 55.3 LIPARA 103 132 78.0 MAMOUROUL 18 105 74.3 BOU BANDAMA PETONKAHA 107 145 73.8 MORIBABOU a KISSIKRO a TOGO MONO ABASSA r28 157 81.5 WARANYI 159 184 86.4 AKPANGO 74 728 57.8 YOTO AGONIKOPE 4 19 2l.L ADATEKOPE 29 75 38.7 SEDOUKOPE 12 t42 8.5 KARA YAKA 103 119 86.6 SOREDA t KABONGOU I 28 NOT TREATED 29 I\NNEX 2 ANAI-\'SIS OF FAMII-Y QUESTIONNAIRE 'I'able 8. Percentage of individuals treated by village by sex COUNTR Y BASIN VILLAGE FEMALES MALES BENIN GHANA OKPARA MOUMOUDJI 75.4 90.6 ATCI{AKPA 55.2 59.6 AGBOCON 96.8 95.8 SOTA ZOUGOU 87.8 84.8 KABEKA 86.7 89.2 GBEKOU 46.2 37.8 OUEME SAMIONDJI 53.8 58.6 ATTANKPE a DOVI.LEGBA 30.8 37.9 ASSUKWAKW A LARBOANO 71.0 73.7 MUSA AKURA 66.7 85.7 DODO AMAN 55.4 51.1 KULPAWN /MOLE SOMA 50.9 u1.1 BIDIMA 63.9 55.9 KATOA 76.0 19.0 BUI BUI CAMP 88.9 95.0 JENSOSO t MATUKWA 13.9 85.0 NOT TREATITD 30 ANALYSIS OF FAMILY QUESTIONNAIRE Table 8 cont. Percentage of individuals treated by village by sex COUNTR Y BASIN VILTAGE FEMALES MRTPS COTE D' IVOIRE COMOE AHININKRO 78.6 71.4 ETLIIEN.K AMANGOUAKR o 67.5 81.7 59.0MARAHOUE GOATIFLA 51.6 LIPARA 81.1 74.r MAMOUROUL 73.2 75.5 BOU BANDANIA PETONKAHA 71.6 76.1 MORIBABOU KISSIKRO TOGO MONO ABASSA 17.6 86.1 WARANYI 85.6 87.5 AKPANGO 47.8 63.4 YOTO AGONIKOPE 40.0 ADATEKOPE 45.9 31.6 SEDOUKOPE 8.8 8.i KARA YAKA 8r.2 94.0 SOREDA t KABONGOU a 3l ANNIlXES Dr. DARET SEHERI Bernard Conseiller Technique, charg6 des programmes de sant6. C6te d'lvoire. Dr. BRIKA G.P. Directeur exc6cutif du programme national de lutte contre i'onchocercose. C6te d'lvoire. Lr pr6fet de Zounoula C6te d'lvoire. ACOUNAN DEINY Fabien. Infirmier chef du dispensaire de Aniassud (Abengourou). DT.FOUNDHOU FOUNDOHOU Joseph. Directeur 96n6ral de la Protection Sanitaire. Benin. DT.MIDOU Ibrahima.Mddecin chef des Services Techiniques d'lntervention. Parakou Benin. DT.ASOGBA [:urent Coordonnateur National du programme de lutte contre I'onchocercose. Parakou Benin. DT.KOUSSIHOUEDE Georges. M6decin chef de Kandi Benin. DT..AHOSSI Emile M6decinChef de Pobd B6nin. DT.AGUENOU Vincent M6decin Chef i Savd DOSSOU Avocanh lnfirmier d'Etat d, Zagnanando Beinin DT.BATCHASSI Essol6. Directeur G6n6ral de la Sant6 Togo DT.DARE Aboudou Coordonnateur Adjoint du Progrmme National de Lutte contre I'Onchocercose. Kara Togo BODJONA-KAO Patha. lnfirmier d'Etat Waragny Togo. I{OUNZANGBE Kouassi Infirmier d'Etat Tovegan Togo. AIIA Alpha Intirmier d'Etat Yaka Togo. KOUMOU Sami6 Infirmier d'Etat Kaza Togo. DT.KCFI Ahmed Director of Public Health Ghana- FOSSO KOJO James Excecutive Director National Oncho Secretariat. Ghana. DT.AMANKWA Joseph National coordonator onchocerciasis control Chana. DT.KANDA G.K. District Medical Officer Hohoe Ghana OLIVIAKUNYENGNEH. Nurse chief of health centre Matukwa Ghana. HODJA Marguerit. Nurse Chief of health centre Toa kurano Chana. GWYDEH James Walenten Nurse Chief of healrh centre Dodo-Amanfrom. Ghana. TINGAN Mary Nurse chief of health centre Bulenga Ghana. 32 ;.i. 4 au Be.nin. au Togo et au Ghana. Des entretiens avec les autorit6s au niveau central (Ministdre de la Sant6), avec Ies responsables a, nireau regional et p6ripheriqu:, il apparait que la.distribution de l,ivermectine est prise en corpte cornme une strat6gie de lutte contre l'onchocercose' Mais sa mise en oeuvre en faiie avec de sp6cificit{s d'un pays i un autre' I-^a distribution de l'ivermectine est principalement assuree par des 6quipes mobiles dans les quuir" pays, 6quipes constitu6ei par la coordination nationale du progru*rne de lutte contie -l'onchoiercose. Celle-ci s'associe des agents de sant6 au niuJuu pfripherique en COte d'Ivoire, au Benin, au Togo, au Ghana dans certains bassins. Au Ghana les agents de sant6 sont associ6s au traiiementdans-les bassins de la Mol6. [r niveau p6riphErique est trds peu impliqu-d dans les actvitds de traitemint, de surveittance et de iuf.*ition dans les'localitSt .i-t ng1l ?vonq 311]:t llqu0tes ].part Bulenga. Mais li aussi le personnel avait fait sa derni0re ,.t;P:X:\"-" en mai 1994' Au Ghana t'implicatioii;ri;;1";d".; eroitqut le ag9gti d9.s11fad1nulelyls-9nt impliqu6s Jans le bassin de i" rviore-t"eux de Dodb-nmanr1s1,iae..Naqlly,1-d_: loh'idnu'ne le sont pas. [l s'agit te di centres^qui sont proches al "iiiagbi que'nous avons enqu€t6s ou qui sont m6me dans ces villagei (cas des deux derniers cit6s). : En C6te d,Ivoire la supbrvision et la surveillair,ce sort sous Ja responsabilit6 de la direction de la sant6 communautaire qui a €iabord un plan de supervision-deS.soins de sant6 primaires a aur les niveaux. Il n'"tt pas encord op6rationnel, mais la supervision et la surveillance dans le cadre du traiiement de'l'onchocercose pourrait selon le conseill.;;;.h;iq,* siinscrire dans ce pt*.Al Benin les age.Pls 'de sant6 ne participen, pu, tous uu niveau p6ripheriqY" "Y +,i*6t de supervision ej de surveillance et n,assurent pas le traitement passif qui'.rt fait i sav€- et ilKandi seulement dans les z6nes d'enquOte. Au Togo dans queqr., .", des agentsde sant6 au niveau pdripherique parricipent ) Ia supervivion et d Ia suheillance. C'JSI le cas par exemple.de I'infirmer de Kaza qui aprds enuoie selon lui des rapports de supervision et de surveillance du traitement i Kara. Il profite de ses ,rp.*irions pour sensibilisdr et surtout dans les cas de reactions secondaires- Dans tous les quatre pays la supervision et surveillance sont des activit€s exc6cut6es essentieller"nt p., ies equipes nationales. Au niveau p6ripherique les agents lunqu"n, la difficult6 de la supervision it de la surveillance sans moyens de d€placement' 2. Lr mise en place du traitement communautaire [r traitement communautaire est ] ses debuts dans les quatre pays. Dans les villages enqu0t6s il est en oeuvre seulement dans deux villages du Benin: Dovilegbado er Atchapka, dans un village de la C6te d'lvoire : Ahininkro. Dans le bassin de la Como6 I'infirmier d'Aniassu€ est "chargd de la mise en place et de la sUpervision du traitement comntgnaLrtaire. Des entretiens avec les responsables <les ministdreS de la sant6 des (lr.lilrrc. peys, il ressort qu'il y a une volont6 d'une plus grande implication des -e 33 communaut6s danS les activitcs clcltrtte contre I'Onchocercrlsc En C6te <l'lvoire I'adh6sion au traitement communautaire a 6t6 affirm6e par le conseiller technique charg6 des programmes de sant6. Il est envisg6 l'int6gration des activit(s de lutte contre l'onchocercose aux soins de sant6 primaires dans le cadre de l'initiative de Bamako. [a mise en ptace ctu traitement communautaire a commencd dans le bassin Ce la Como6. Au Benin le Directeur National de la Protection Sanitaire a dit que l'implication des communaut6s est une prioritd des autoritds: Ainsi les populations seraient d6jd associ6es ir plusieurs programmes. Elles y ont 6t€, pr6par6es grdce i une mobilistion sociale assui6e par un systdme d'information i base communautaire. Par ce systdme les villageois sont d6ji form6s et impliqu6s dans des activit6s de sant6. [-es autorit6s vont pro*ouuoir cette demarche dans la perspective du traitement a I'ivermectine. Au Togo le Directeur G6n6ral de la Sant6 Publique a d6clar6 que le traitement communautaiie est envisag6 comme un moyen de pdreniser les acquis de OCP. Ainsi il permet une prise en charge de la sant6 par les communat6s dans le cadre de la i6centralisatibn. Mais selon le coordonateur de Togo les populations doivent Otre pr6par6es i cela progressivement pendant les prochains passages des 6qu.ipes mobiles. irui"*"*ple le chef du poste de sant6 deKaza a d6clar6 que des volontaires villageois Sont formes dans tous les quartiers et dans des villages voisins Au Ghana le Directeur G6n6ral de la Santd Publique a d6clar6 que l'implication des communaut6s fait partie du processus de d6volution. Mais que c'est surtout dans la partie sud du pays que des volontaires villageois ont 6t6 form6s dans ce sens. Dans la partie nord du pays Ia distribution de l'ivermectine se fait selon un plan vertical- Des tomit6s villageoij sont form6s avec une fonction d'intervention aussi bien dans le domaine de [a sant6 que dans d'autres domaines comme le d6v6loppement. Mais Ie directeur exc6cutif du s6cr6tariat national de la lutte contre I'oncocercose affirme qu'i l'heure actuelle ces comit6s ne sont pas fonctionnels. Au Ghana dans le district de Hohoe des volontaires villageois ont 6t6 form6s et ont commenc6 Ie traitement corrrmunautaire dans trois villiges: Kujura, Kleju et Wegbe. Mais le m6decin du district de Hohoe dit qu'il n'a pas pour le moment un vrai plan d'implication des communautds dans la distribution de I'ivermectine. fu coordonnateur national de Ghana a mdme apport6 une modification au dernier plan qu'il a envoy6 a OCP en y introduisant le traitement communautaire comme strat6gie d'iniervention dans la distribution cle I'ivermectine. Il envisage d'intensifier I'IEC et la formation pour une plus grancle implication des communautes. Cette implication des communaut6s est aussi envisag6e au Benin oil Ie coordonateur national veut d6sormais privil6gier le traitenrent communautaire. Il est a noter que ce type de traitement a commen.6 ,u Benin dans deux villages parmi les villages enqu0tds. [-a particiation communautaire est une strat6gie clont la mise en oeuvre est consider6e comme un moyen d'auqnrenter la cttuverture au Togo comnle en COte cl'lvoire. i*' ;:- .b -: ,:, 3rmatlo sle Il ressort des entretiens avec les autorit6s et les resptlnsables de la sant6:) differents niveaux dans les quatre pays que si Ia formati<ln du personnel sanitaire est consider6e comme comme une n6cessit6, les pays n'ont pas toujours un plan de formation i tous les niveux pour mieu.x le pr6parer i intervenir dans le traitement. [,e personnel sanitaire cles z6ne.s cle distribution de I'ivermectine n'est toujours pas associ6 i cette activit6. En C6te d'Ivoire il n'existe pas un plan de formation i proprement parler. Cependant une reflexion est en cours dans ce pays selon le conseiller technique charge dei programmes de sant6 pour l'6laboration de plans de formation initiale, de formation contlnue et de formation en cours d'emploi en tenant comPte du paquet minimum d'activit6s par niveau du systdme de sant6. Au Benin les agents de sant6 sont formds sur diff€rents programmes avec les :. paftenaires. Ils sont form6s selon le Directeur 'de la Protection Sanitaire au paquet hini*u* d'activit6s comprenant toutes les pathologies locales. Cependant au niveau '', p$ripherique (pr6fectures et sous-prefectures) Ies responsables de la sant6 affirment ne pas ivoir d. piunr de formation. [rs agents n'ont pas 6t6 toujours form6s. Dans le cadre de traitement a I'ivermectine c'est la participation qui a €t€ la formation des agents i l'activit6. Au Togo un plan de formation est 6labor6 et ex6cut6 en collaboration avec OCP selon le Directerr Gen6rrl de la Sant6 Publique. Il s'agit de formation de longue et de courte dur6e dont doivent b6n6ficier les agent de l'6quipe nationale, des 6quipes de z6ne comme des agents des centres de sant6. Mais le niveau pdripherique ne dispose pas d'un plan de formition. t-a Direction de la Sant6 Publique a proced6 au recensement de tous ies agens de sant6 qui ont 6t6 form6s par le programme OCP en we de leur faire appel "n *r de besoin dans le cadre d'une plus grande implication de l'Etat dans les activit6s de lutte contre l'onchocercose. Au Ghana le plan de formation concerne le niveau des regions et des districts et m6me le niveau p6ripherique dans le cadre de Ia surveillance dpid6miologique. Des comit6s de districts sonr form6s et les ONG aident i la formation en cascade dans la region Est. Mais dans I'ensemble au niveau p6ripherique il n'existe pas un plan de foimation dans le caclre de la lutte contre l'onchocercose dans la mesure oi le personnel sanitaire n'est pas toujours impliqu6 dans les activit6s de traitement. ifi Dans le cadre de la gestion <Ju programme, les strat6gies sont similaires bien en ce qui concerne la planificiri<>n et la prise des d6cisions dans les quatre pays. En C6te d'lvoire tous les niveaux p:rrticipent i la planification et i la prise des d6cisions' Au Benin pour la planification et la prise de d6cisions la ctlordinatitln du programme travailli avec le comit6 national cle Iutte contre I'onchocercose et la Direction de la protection Sanitlire. Au'l-oto l:t pl:rrrit'icution et lcs prises de decisiorl \/()rlt des initiatives de blrse. Arr G5:rntr l:t plarrrl'r crrtion ct lcs priscs dc tlIcisitlr]\ s()ttt iltites lltt ttiVt:ltLI .: 4national ct au niveau des districts. 5. L'approvisionnement et la gestion de I'ivermectine En C6te d'lvoire il est envisag6 de mettre I'ivermectine dans le circuit des m6dicaments essentiels i travers la Pharmacie de la Sant6 Publique. Aussi pour la gestion de I'ivermectine ils suggdrent que l'6quipe nationale puisse Iaisser des stocks de comprim6s ) I'infirmier chef qui pourrait s'occuper du traitement des absents par exemple. Au Benin l'ivermectine va de la coordination aux centres de sant6. Au Togo la coordination regoit de OCP I'ivermectine et elle approvisionne les directions d6partementales de la sant6 qui i leur tour approvisionnent les centres de sant6. [: Direction Gdn6rale de la Sant6 Publique envisage de mettre I'ivermectine dans le circuit des m6dicaments essentiels. Au Ghana l'approvisionnement en ivermectine se fait selon la m€me demarche. Sa distribution est assur6e par l'6quipe nationale et les ONG qui interviennent surtout dans la partie sud du pays. 6. Suggestions et perspectives pour la distribution de I'ivermectine Il ressort des entretiens que les autorit6s sanitaires des quatre pays veulent promouvoir le traitement comme une strat6gie de p6renisation des acquis de OCP. Dans le cadre de leur collaboration avec OCP les coordonnateurs voudraient plus de feedback i leurs rapports de traitement car ils n'ont pas toujours une appr6ciation de leurs activit6s. 5I'rohldmes actuels et obstacles i l'6levation de la couverture du traitement d I'ive rrne ct ine. D:rns les quatre pays certains probldmes revel6s constituent un obstacle I Ia perlorrnence dans la couverture du traitement i I'ivermectine. l. L'information. Il y a trds souvent un manque d'information sur Ie traitement d I'ivernrectine et sur le jour du traitement ou mOme le lieu. I-es dquipes semblent privilegie.r I'administration du m6dicament I I'information sur le traitement lui- mOme contrne cela ressort des causes de refus de certains d'accepter le comprim6 ou de continuer le traitement. En effet les raisons du traitement ne sont pas connues de tous ie.s chels de villages. Certains ont m0me affirm6 qu'aucune explication n'a €t€, donn6e cllrns le village i ce sujet: cas I Vanierotifla en C6te d'lvoire dans le basin de la NI arrr hrlr:i. Les 6clrripes auraient donnd peu d'informations sur les reactions secondaires. Ainsi i Sarlionclji au Benin un chef de famille a pris les comprim6s pour les membres de sa farnille ct les a gard6s pour voir ce qui allait arriver I ceux qui ont pris. Comme il y a eu beaucoup de r6actions secondaires le chef de famille en question n'a plus donn6 les conrprim6s aux siens. Des cas de refus ont 6td motiv6s par les reactions aussi i Gbekou ,d Moumoudji au Benin. A Larboanu au Ghana une famille a refus€ le traitement de peur de voir ses membres invalides pendant la pdriode des travaux champOtres. I-e chef dc iarnille nous a affirm6 que, ne sachant rien sur le m6dicament, il a pr€fer| ne pas prenclre de risque de compromettre sa saison. A Matukwa au Ghana une femme aveugle a refusi le traitement car pour elle, cela ne lui sert d plus rien. A Dovilegbado au Benin certaincs femmes ont refusd I'ivermectine considerde comme un produit contraceptif. L'irr[ornration concernant le traitement n'a pas 6t6 toujours bien diffusde dans Ie villlge. ,{,insi i Gbekou une partie du village n'6tait pas inform6e du traitement. A Atchakpu au Benin of le traitement communautaire est en cours plusieurs personnes et rnerne des familles entidres n'dtaient pas inform6es de l'existence de l'ivermectine dans leur vill:rge. A Ackpango au Togo une famille enquOt€e n'a jamais 6t6 informde du rrairement. Il en est de m0me pour plusieurs personnes i Adat6kop6 au Togo, i Katuwa au Ghuna. I-'information sur le traitement,la compr6hension des raisons du traitement ont un,: grancle incidence sur Ia couverture. L'illustration en est donnde par le cas de Rui-Carrrp au Chana oir on a le taux de couverture le plus 6lev6 parmi tous les villages enqtr0tis 92,1o/a. Il s'agit d'un village de salarids de l'Etat cr66 d I'occasion de la constrlrcion d'un barrage. [)lns les cas de traiternent communautaire au Benin les personnes charg6es de certe activit6 6taient peu inform6es sur le traitement et meme sur ses raisons. lrs deux clisrribureurs qui 6taient pr6sents le jour de I'enquOte connaissaient d peine la posologie selon la taille. Ils ont affirm6 que celui qui s'y connait mieux est.parti d Cotonou. 2. Une ccrtaine pratique du traitement. Certaines pratiques des 6quipes mobiles conslcrcnt I'exclusion d'une partie de la p<lpulation 6ligible au traitement. Par exemple I I 6la liste de traiten'lcnt est 1'111[rlic'unc f<lis [)()ur toutcs.,,\ittst Ics absettts au prcmlcr traitement, les nouveaux arrivants dans les villages sous traitemcnt ne sont plrrs pris cn compte m6me s'ils se presentent aux traitements suivants. De tels cas ont 6t6 rencontr6s surtout au Ghana dans Ies villages suivants: Katuwa, Dodo-Amanfrom, I-arboanu, Musa Akura,et i Bidima. Il est A noter que des enfants se sont vu refuser le traitement par les 6quipes mobiles sous pretexte que leur pdre ou leur mdre n'6tait pas sur les lieux. De m0me certaines femmes n'ont pas 6t6 traitdes parce que leurs maris n'6taient pas pr6sents. De tels cas ont 6t6 rencontr6s i Gbekou au Benin, i Yaka au Togo, i Soma au Ghana. Aussi dans la plupart des cas des comprim6s ne sont pas laiss6s pour le traitement des absents. AIors qu'il exite un centre de sant6 i Dodo-Amanfrom, l'6quipe n'y laisse pas de comprim6s pour le traitement des absents. Ces derniers doivent se rendre ) Dodo-Papase pour etre traites. t-a plupart n'effectuent pas ce deplacement qui leur co0te et du temps et de I'argent. L-a p€riode du traitement a souvent 6t6 un obstacle i une bonne couverture surtout que I'information n'a pas 6t6 toujours donn6e sur le jour du traitement . Ainsi certaines familles vont au champ et ne reviennent pas avant le d6part de l'6quipe. Aussi le jour du traitement d'un village doit 0tre choisi en fonction des 6v6nements dans le village ou dan les villages environnants. Il s'agit notamment de tenir compte des jours de march6 hebdomadaire. [.e cas du village de Sedoukop6 au Togo dans le bassin de Sio-Yoto-Haho en donne une illustration. De tous les villages enqu€t6s Sedoukop6 a le taux de couverture le pus bas 8,57o. En effet ce village a 6t6 trait6 un mardi, le jour du marchd hedomadaire du village voisin situ6 I moins de trois kilomdtres. Presque tout le monde i Sedoukop€, €tait parti au march6. De I'entretien que nous avons eu avec le chef de Sedoukopd il ressort que celui-ci avait demandd i l'6quipe de venir plut6t un dimanche jour of tout le monde est present. 3. te traitement des hameaux ou des villages regroup6s. Si les villages mdres sont trait6s souvent les habitants des hameaux ne font pas le d6placement pour venir le jour du traitement. Ainsi certains villages voisins de [-arboanu ne sont pas venus pour le traitement dans ce village. De m0me le village de Senawo ir moins de dix kilomdtres de Soma au Ghana n'a pas 6t6 trait6. L,es habitants de ce village sont enregistr6s pour le traitement i Jam un village plus gros. Ils n'ont jamais fait le ddplacement. Cette situation affecte la couverture g6ographique. Ainsi des villages ou hameaux qui sont suppos6s 6tre trait6s ne le sont pas en fait.
DISCUSSION CUIDIl ON IvEITMEC'flN TREATMENT Cotr n t ry I)atc. I ..1 Narnc oI respondcnt L,evel in the national health service. I Central 2. Regional 3. I-ocal (District, Subdistrict) Introcluction. The national onchocerciasis control prograrnrne based on ivermectin treatrnent has, for a lorr:: tirne, been supported by OCP, NGOs and thc Sovernnrents corsidered separately. It is rtell knou rr that (he greater part of the external support will ce.rse soon, i.e. in 1997. In your opinion, nh:rr ts the most effective approach the national authorities would adopt to Assunle their full rcsponsibility in the programme with regard to the following points: What plans do you have for increasing the participation of the communities concerned with tlre programme (community participation). II What plans are in place for staff training at all levels of the health system.. III With regards to management of the programme, i. how is planning and decision going to be done ? n Supervision and surveillance? ul Supply and delivery of ivermcctin a lverm5a NATIONAL COORDINATOR SURVEY ON IVERMECTIN TREATMENT IN OCP PROGRAMME PERFORMANCE Date t_1 Countryr Name of the Programme manag er '1. Do you have a work plan for the rest of the year ? 1.1 ll YES, give the coPY 2.WheretheremajorchangesonyourlastplansenttooCPHeadquarters? 3.lfYEs.inwhatwaydidthechangesatfecttheachievemento|yourtargets? Yes/t'Jo Yes6'lo 4. How long usua.lly do you submit your results to OCP atter treatment ? 5. How large is the team lor a treatment visit ? 6. Average number of people treated per trip by each team 7. Do you plan lor ivermectin supply for the year before start treatment ? 8. How many 'emergency calls' for drugs have you made sirrce last two years ? 9. ls current stock of ivermectin sutficient lor next treatment ? 10'Doyougetanyleed-backlromoCPHeadquartersaboutyoureturns? 11. what activities are you undertaking for staf( training at all levels ? (in weeks) YesNo Yes/No fl Yes/t'{o t-l 12. What actiMties are you doing to increase community participation ? 13. Have you trained anybody to give ivermectin treatment ? 14. Do the volonteers work by themselves ? l5.Whatchangeshaveyoumadeorwouldliketomakeinivermectindistribution? estion ? YesA.lo YesAlo I I 16. AnY other sugg I'lcasc collcct tlrc trcatntcnt fornrs bY ()Ol' for thc villagcs survcYcd lr ri ;i VILLAGE QUESTIONNAIRE SURVEY ON IVERMECTIN TREATMENT IN OCP ,[-l-l-l-1- L] country:l- -- [ -] vrttqse: Population size Name of villag e chief or school teacher resP onding 2.2.11not, have you been treated with tabtets by another person? 2.2.1 lf yes, by whom? (N GO/CO M m unity/PASsive/M O Bi le) ,l tvermqaril I Date rri-lt ! _, 1-_ l t, 1 . - what is being done for prevention of blindness in this village ?(lVErmectinfflTa/OTHer/NlL) 2. - Has there been, in your village. a team making treatment for the prevention (Yes/No) of blindness? 2.1.Was this team in an Oncho vehicle marked with a big red circle? (Yes/No) (Yes/N (Yes/No)2.3.Did the team which treat you use an equipment for welghing or measunng nelgnt'I 2.4.How many months ago did the last treatment take place? 2.5. How long does the team spend during treatment ? (hours) S.- Who, in the village, participated in the organization of the ivermectin treatment? WHO IN WHAT WAY 1 2. 3. 4.- what were the reasons given you for the ivermectin treatment? 2 3 5.- Were there probtems during the last treatment cycle? (Y/N) 5.1.{f yes, please speci 5.2.According to you, how can this problem be solved ? 6.- Would you like the ivermectin treatment to be contined in your village? (Yes/No) 7.- Would you like another method of distribution of the drug ? (Yes/No) 7.1. lf YES, please specifY (NGO/COM m unity/PASsive/M O Bile) (Yes/No) I -l8.- Has any body been trained to treat in this village ? 1 lverm3an ',t NSTRUCTIONS F*Q,R THE INTERVIE:WER SURVEY ON IVERMCCiIT TREATMENT IN OCP J .-+, AGE :Record two digits SEX : Record M for male and F lor female I OUESTION 01 QUESTION 04. QUESTION 05 When the team arrived for the ivermectin treatment of the population did you receive tablet(s) ? Did you take the tablet in the presence of the tearn ? How did the tablet act on you after taking il the last time ? IF YES TO OUESTION 01 qUESTION 02. How many tablets were you given ? Record the number : 0.5, 1.0, 1.5, 2.0 QUESTION 03 Does the tablet resemble any ol these ? Show an ivermectin and multivitamin tablets to the one questloned Y/N Y/N Y/N ,l il il ,i L 1i il il it ii tl il il li li ii 1. Beiler 2. Nothing 3. ltching 4. Pain 5. Dizziness 6. Rash 7. Oedema 8. Other QUESTION 06. lf you felt uneasy during the first two days after taking the tablets ' what did you do ? 1. Nothlng 2. take tablet 3. Go to clinic qUESTION 07. How many times have you been treated already ? Record the number IF NO TO QUESTION 01 QUESTION 08. Why did you not receive tablest during the time the team arrived ? 1. Absent 5. Shortage 2. PregnancY 6. Not interested 3. Under 5 years 7. Other 4. old QUESTION Og. Have you taken ivermectin tablest since the last treatment ? Y/N QUESTION 1O. Do you intend to take ivermectin tablets next time ? QUESTION 11. lf no to question 1O, why ? QUESTION 12. How long should people be trdated ? Y/N i ii I li I I I l I ir I I l I I i I c\J o o i! I .t ilttil @ oR E o) tJ_ a oE ]C o (6 ob @ 0)o c oa -o ciz 10 E E,q) o =o - o-() o z Fz IU F r,u(rF z tro IU =cc TU z o l.U E, a LU z q iu C,)(o 5 o o > 6z o) o >62 o o o C = @ o oA tIJ(rF -{ A6U 9ur *1.4 E gzZG zl-EHStso"5HfrrrZJOIF < o.fOz0,O -c{c'i.qrrttcir- o (o o F TU)oqz<L3FrrE EVZHl) 4 Jl-Zl:()O -oi<.js l4t o n?E fr Efr=z 2-*E EEE=NEHE@z)-o"ocEoO Joiai.frtd,-d !r o > 6z (Y) o L> oz o o o 0) = q o rootr,o ci;;cli o > oz (/)wx 2 oLL a <Ot! OOoruu) o (r)o rlo lno @o o @o o,o o N cr)Noz N E o2 LU cc az zI a r,u :) o oJ o r.u U) :E 5 aEC .9 c{,c o q)E '=e bo q)o 5U 'ao (J- ., GlE: (l) a.) '6'6 trcdcoo v, thoo dct o(u EE()9 oq)oo@((,(E q) t< C,cc o t)(u d ! o q) at, o (.) c) (l(!cccC .9 .9 t) tttoq)(to(,) (u cr(J(uo oo@ct(I, z r'5 =C .9 CJ z o q) .= ,a(uh EHotr o: OE Ee6 co oZ- EE$ .eOH E EE EGt q) v1 edtrEA .3 .y!s 2IB .au6. O o oJ o o o FI! <z q) L '- q) c! ^.L d.9q)e -- o)v= bcr 9o Yo 9l >:E ,< 'E9€'tq) o:, t^ 9P; k E Tg; g =- €'s .9cio..lg;c,; .38 .E.E € .EE :€ $g fr- gc"r; 9oof,E:-.;E Es u o EEtSg$ EE=s',8tsts;s&= ggE!.[i *g$gl ;EiE Etlg x Ic(u tr (g q) 'o & oF 9 o Z I(!() \o E(l) .38 H -r= <D(t'L -C(l.)e .- bO E1J-: o-j0,= .!r, d => b9o 66 o-tsE: [E -F:1 e9 rvq2= o trl6)I.<ep'' 5 :i€ G,(E 's.Es Y PE! *;8 ssts+il ;ltrlq)(l)oEE€ E i" :ECiUE E i;iE [€ ti! E H:EE E:= ii;;€E E€; e Hog SSE:E;;; g SEsSEsEfgg i >'5 cq) E .E E oO cletr!o!2 -- tL({E At) $ v l- o 8=Ce(€>r bs LO a)o-! q.)(U L>\ ctJ sts o{) L) O. A) a c-) o oq) o.Ul Eo '60 o o '6 oa c.i () E cd o sl E rl.) co o (l) oO(I, q) oo o c(.) E U)U)q) c '6 )o ,r, -bp .98 o- L -troEEo= --o?d 5E E +a (L) ..(I,oEtrtrcl E# *+8f, r! (, o o. Fz tll l-k r!/F z r- tr o 2,d r! z tL o z o F ) --1 iL) r! F & o(L v)& oF q o = SITUATION DES VILLAGES ENQUETES AU GHANA BURKINA FASO ,V.srI TAMALE o o end o .a d- ooot- t!g o -a Hoo BuiCamp./.\/\ \,/, % Bankama KUMASI o New Dodo Musa Aku ..r\ o o' a ACCRA lage enqu6t6 le importante o vil o Vil Wa o ,& -_-J L % Sekondi Echelle 1cm = 35 km _5 +@ra,.t I}tI r;t, SITUATION DES VILLAGES ENQUETES AU TOGO BURK|NA FASO GHANA O Mllage enquet6 O Mlle importante - Limite sud de l'aire initiale BENIN Echelle lcm = 25km c-*ffiE . r, r o Sota Nikki o o o T6rou e &t o o Bohicon TOGO SITUATION DES VILLAGES ENQUETES AU BENIN N/GER BURKINA FASO NIGERIA O Mllage enquet6 O Mlle imprtante COTONOU Echelle 1cm = 30km C4c@r@4 rG .l-- . ^ ., r:-6--a!-:*-:--i{\ffi&' t n:' -^ '1.- J:. . . -__ !i,..Eirt.it:rr$^ rr-, a t - SITUATION DES VILLAGES ENQUETES EN COTE D'IVOIRE MALI BURKINA FASO LIBERIA nd Lahou ABIDJAII 'a \-- ]JJ tX ) o ) e s o boua o Village enqu6t6 Ville importante ca o Katiola o o b \Q+ Kouadiko a mbokro g\ a Gagnoa o s ao Man (( (^) t & z1$ .o' i CartoCEphrc OCP / vCU, R TOE Mar 19Oo o Echelle 1cm = 40 km