Training module for peripheral health workers

*-' WHORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE I-A SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQTJE DE L'OUEST TRAINING MODULE FOR PERIPHERAL HEALTH WORKERS ocP/EPL/DOC/94.21 INTRODUCTION TheonchocerciasisControlProgramm"(:."].:."WestAfricahasbeenoperational in the savanna ur"u. of seven west -et i.ur, co.rr,tri.. ( Benin ' Burkina Faso' cote d,Ivoire,Ghana, Mali, Niger uro rogoj ;;." 1975. As from 1985 the operational area was widened to include: (a) the western extension areas' comprising of Guinea, Guinea Bissau, western Mali, Senegal and Sierra leone and (b) the Southern extension, made up of the southern parts of Benin, Ghana, Togo and COte d'Ivoire' ob e41v9--q tbe Pro raElqg The objective of the programme has Deen uu "" r"*. O"u"lop*"nt throughout the ffiHJ:ij***r:ii;y"f tx};,:?,ffiTl:x':i::"i;illln'"",.main'lain this achievement ' y of the Programme rh is obj e ctive h as b e e n pur sue d thr ou:l ^tT.::1.fl"iil:?',HJf'": :liil'"i:l ,.,",ril;'*::ffi'::"H,'"T;:T;:: :J;i;";;."ftio,, ot the Programme *rowever' since 1987/88, drug tfeatment- -i'e r".,*"ai1 t'^"u"* added to the control efforts primar,y to, *oruiaity contror; the'fkst objective of the drug treatment being to treat initiarly those at highest risk of orr* orrrrdness, with subsequent treatment of all those infected with the Parasite' white the vector control activities have been carried out largely by ocp staff' the control through chemotherapy has u""., ,rna"rtaken by national teams with ocP support through ,u.g. ,.ui"-iir,riurti"n of ivermectin. I-arge scale treatment has been confined to carefulry defined areas that satisfv set down criteria' 'n"'" "]: n:::l;;J.t:T'il"t:it[1: donotmeetthecriteriaforlargescaletreatment,butmayanddohavert who may ue treated through ott,", *".t,anisms, as for "*u,np'", through passive means. The impact of these control measures have been measured, among others, through epidemiorogicar "uuluutio.rs carried out by nationar teams together with ocP staff' *' "!- 2With the reduction of the disease to levels at which it is no longer of public health and socioeconomic importance in the respective countries larviciding will cease or has ceased. The countries are thus ushered into the phase of devolution which is the taking over by these countries from the OCP those activities which will help maintain and strengthen OCP achievements. In this respect and in the context of this manual the two main activities to be performed are epidemiological surveillance and treatment through ivermectin distribution. The aim of the epidemiological surveillance is to keep a watch on the epidemiological situation through periodic active case detection, be in a position to promptly detect and confirm any possible recrudescence of infection and take the appropriate control action through ivermectin distribution. The overall goal of this manual is two-fold: i) to train and equip the peripheral health staff to be able to diagnose and treat onchocerciasis cases by passive means and ii) to train staff at the district level to be able to undertake active epidemiological surveillance and large scale ivermectin distribution. A. GENERAL a. Peripheral health workers . There are three levels of operation in the structure of the peripheral services: lrvel A - Community level workers who are usually volunteers. They include community clinic attendant and traditonal birth attendant. lrvel B Irvel C Basic health institutional level with nurses and technicians. District hospital from where the District Health Management Team operates. It is the seat of administration of district health delivery with personnel of higher qualification. b. Objective of the training The objectives of training are: ffifi'u- 3 1. to equip the level B and C peripheral health worker with the know-how and the ability to diagnose, take appropriate action when he is confronted with a patient or suspected case of onchocerciasis and to manage onchocerciasis data. 2. to make it possible for trained level B and C health workers to undertake the training of level A health workers. 3. to equip the level C health workers to be able to undertake active epidemiological surveillance and large scale ivermectin treatment. c. Specific objectives At the end of the training programme the peripheral health workers, given the necessary tools, should be able to: 1. Give an account of: - The causative agent of the disease - The vector that transmits the disease - The mode of transmission of the disease - Clinical manifestations of the disease (signs and symptoms) - Complication(s) of the disease. - Distribution of the disease in his country, and in the OCP area. - Public health importance of the disease (ditto). - Importance of migrants in the transmission of onchocerciasis. 2. Make presumptive diagnosis through - relevant history taking; - proper interpretation of early symptoms of disease; - proper inspection and palpation of the body for identification of onchocercal lesions and possible nodule. 3. Make definitive diagnosis - through filling in an appropriate Iaboratory form. - sending suspected patient to an appropriate laboratory for skin snipping - reading and interpreting correctly laboratory results when obtained. 4. Take an appropriate action by giving correct treatment filling in an appropriate form after treatment. referring appropriately 6. Train level A workers by: showing them simple clinical diagnosis on conhocerciasis; encibling them to refer a presumptive and suspected case to a higher level. This will be achieved through proper recording of data proper filling in of records proper retrieval of records simple data analysis management of new cases correct interpretation of analysed data timely transmission of analysed information to a higher level request for feedback on information. 8. Health talks to infected individuals about the mode of transmission, symptoms and treatment of the disease. Health education of the general public about early symptoms of the disease and the need to report such symptoms to the health auihorities. use of visual aids to make the public understand the disease better. (Annex 1) organise an active epidemiological surveillance in selected villages Obtain and record characteristics of villages examined. Undertake a census of the villages concerned. Undertake parasitological examinations using the skin snip technique and microscopy analyse. To organise and analyse data obtained from the above. throush: 9. 1.0. 1.1. t.2. (Annex 2) TRAINING Parasite. vector. life cycle. clinical presentation Causative agent of disease - Agent : Onchocerca volvulus. - Habitat - Sub-cutaneous tissues of man - Adult worms are coiled together in sub-cutaneous nodules which may be visible. - Female worms produce millions of microfilaria, which spread throughout the skin and other organs including the eyes. The vector - A fly of the germs Simulium commonly called blackfly. - Only a few of these species transmit the disease in min. - These vector species of the disease belong to the Simulium damnosum complex. - There are forest as well as savanna species. - They are found mainly along watercourses because they breed in fast flowing waters. - These flies are tiny, but can fly long distances, up to about 80 km in 24 hrs. They can fly even longer distances when they are aided by winds. 1.3. Breeding of fl,v (life cycle) (fig.1) - Eggs are laid by female adult fly on rock surfaces and debris just submerged in the turbulent areas of the flow, where oxygen concentration is high. - Eggs require high concentration of orygen to develop. - The eggs hatch into larvae, then to pupae and eventually winged flies. It takes about 10 - 14 days for eggs to develop into winged flies. 1..4. Transmission (tig.Z) - During ft1 blood meal, (necessary for the development of its eggs), the adultfemale blackfly picks up microfilariae which are in the skin, together with blood. Life cycle of the blact flJr Fig-1 Real size about 2 nl d(rale) AOUTT I (Ferale) \ Real 4m gutE ?u ta(in cocosrl Ilevelops into adult nale or fenale Rm-l st'^ 7to8u t1 lott tAiYAL RWC Source: - OCp UATB.fAL - WManual \ FIG. 2. LIFE CYCLE OF ONCHOCERCA VOLVULUS Onchocerco volwlus A Mrcrof ilerirc \ Adulr in iubcutanGou5 / Subcuttnrout trsrus IIIII through fly bira wound tlltuc fi HOMO SAPIENS I -- lntecrrvc rr.ec I \ Micro{rtrria in rkin Mrgratlr to hcrd rnd proborcrr # SIMULIUM /= lngcatcd / Penetrat6 rtomach / acrc mutclelru Thor/Larva (sauiage lorml@< hd stage Iffya t The Disease //{it' Fig-3 Arlult wornr. Microfilariae introduced by fly matu re in su b- cu taneous tissu e s. Females rneasure about 50cnr. Malcs about 4cm. Worms o[ botl: sexes are found coiled together in nodules. Nodules Ittftl :_f +g;r People strffr:rinr; frorn onchor;orr:iasrs rrsually have nodulr:s rrr dil ir)roltt l)arts of tlrr: lrorly I t.' '-J'" I _ +r; 7._. - Ii,t!i ,1, l ii '/; llffi 9The adult male fly feeds on plant juices and does not transmit the disease. most of the microfilariae ingested are imprisoned in the peritrophic membrane and digested in the stomach of the fly. Some manage to escape, pass through diffeient stages, penetrate and enter the muscles of the chest of il" ny urrJ g"t to the head where they develop into infective larvae; these different changes lasting 8 to 10 days. The infective larvae enter the biting parts of fly and when next the fly feeds on man, the infective microfilariae are injected into the skin. The infective larvae grow into maturity in the sub-cutaneous tissues where they couple, often forming nodules. These nodules contain male or female adult worms. After about ayear, the female worm starts producing microfilariae into the skin, and the transmission cycle continues. The adult female worm lives about L4-15 years before it dies. The life span of the microfilariae in the skin is at most two years. 1.5. Clinical manifestations of diseases L.5.1. Early signs and symptoms. - The symptoms associated with onchocerciasis are due to the presence of these microfilariae in the skin and eyes. - Reddish rash associated with intense skin irritation, visible on a light skin. - Mild and intermittent skin irritation - Disturbance of sleep due to intense skin irritation' - Scratch marks may be seen on skin. - These different lesions are mainly found on the lower part of the trunk, buttocks, thighs and legs. - In ,o-"'.urJr, a fibrous tissue reaction occurs around the adult worms and produces nodules which can be seen and palpated, especially around the parts bt tt e body where the bone is superficial (head, chest and iliac crest).(Fig.3). L.5.2. I-ate signs and symPtoms. - Wrinkled, dePigmented skin. - Iropard skin - Visual disturbances - Blindness. 10 The eye lesions result from invasion of different parts of the eye by microfilariae. Note: It is important to diagnose and treat before late signs appear. 1.6. Comolications of the disease. - The most serious complications are those associated with the eye. They include : Keratitis, which is inflammation of the cornea. These inflammations leave opacities on the cornea and affect sight. Iridocyclitis which is inflammation of the iris, some small muscles in the eye, and which may lead to increased eye ball pressure. Retinitis which is inflammation of the retina, a very sensitive part of the eye. Inflammation of the optic nerve, the nerve that innervates the eye. Blindness, which is a very late complication. Other complications include unsightly leopard skin and nodules. Constitutional disturbances from lack of sleep as a result of continued scratching of the skin. 1.7. Distribution . The disease has focal distribution in Africa, I-atin America and the Arabian Peninsula. . In Werst \Africa, the disease was present in its severe form in the eleven countries covered by OCP, i.e., Benin, Burkina Faso, Cdte d'Ivoire, Ghana, Guinea, Guinea-Bissau, Mali, Niger, Senegal, Sierra Leone and Togo. . Infection is usually found in populations living about 10 km either side of rivers in these areas. One of the largest endemic areas in West African was along the Volta river basin. 1.8. Public Health and socioeconomic Importance of the disease. Prevalence of disease tends to be very high in endemic areas. Very high microfilarial loads cause serious complications (blindness). Fertile lands are abandoned by villagers because of nuisance of flies and fear of blindness. 11 ' I-owered production and productivity. . The btind become a burden on other members of the family andf or village and the nation. . I-owered output of school children in endemic areas from excessive skin scratching and lack of sleep. 2.O. Makins oresumotive diasnosis. 2.1. Proper history taking. - Has patient got skin irritation or any other symptom suggestive of onchocercal infection? - How long has he had these symptoms? - Is itching severe enough to disturb sleep? - Has patient ever reported at a health institution with similar symptoms before? If so which institution and what was he told was the problem? - Has patient been diagnosed before as an oncho patient? - Where does patient reside at present and for how long? - Has patient stayed somewhere else other than where he is staying now? - What is the occupation of the patient? - Is patient taking drugs, if so what drugs. - Has patient changed the soap he uses for bath? 2.2. Interpretation of symptoms. - Note that not all skin irritations are due to onchocercal infection, thus the importance of taking a detailed history. - If all other causes of skin irritation and or reddish rash are excluded, proceed to inspection and palpation of the body. - L,ook out for possible nodules. Differentiate nodules from other skin conditions like lipoma (soft, not tender), ganglion (turgid and found usually at small joints), inflammatory swellings (painful or tender to touch, may feel hot to touch) or haematoma (bleeding into the skin). 12 3.0. Making definitive diagnosis. - Presence of microfilaria in snipped skin constitutes definitive diagnosis. For non-laboratory technician - Fill in correctly appropriate form to request skin snip or send to one authorised to make request. - Read and interpret correctly laboratory report. 4.0. To take appropriate action. 4.1. - If laboratory report is positive for O.volvulus, must be able to treat or refer appropriately for treatment. If to treat, then. 4.L.1. - Must be able to apply exclusion criteria for ivermectin treatment: a) children under 5 years. b) weight less than 15 kg. c)pregnant woman d) lactating mother in the first week of lactation. e) severely ill patient. 4.1.2. Be able to read scale and determine what dosage should be given to an individual based on weight. ' 15 - 25 kg body weight - Vz tablet '26 - 44 kg body weight - 1 tablet '45 - 6a kg body weight - 1tlz tablets ' 65 + kg body weight - 2 tablets. 4.1.2.1. To repeat treatment yearly. 4.1.3. Proper address must be taken to be able to trace those patients excluded from treatment for subsequent treatment later on. 4.L.4. Fill in correctly, the communicable diseases reporting form and send to appropriate place(s). 4.L.5. Refer or inform appropriate quarters for necessary follow-up and or action. 13 5.0. Manage data obtained through passive detection of cases 5.1. - Peripheral workers in general and record keeping officers in particular should be made to understand proper filing and retrieval of medical records. - Medical assistants and nurses to know and understand record keeping in the consulting room for easy reference. - Understand simple data analysis (old and new cases) Distribution of cases by month and by year. Distribution of cases by age Distribution of cases by sex. Distribution of cases by place of residence or locality. - To understand trends in distribution and therefore recognize any unusual signals of change early enough for action. - To understand and write monthly and annual reports and distribute appropriately. - Proper recording of tablets of ivermectin used. Duties to be carried out by chief health post nurses in zone not on a large-scale treatment. - Identify among the patients all suspected cases of onchocerciasis. - To treat with ivermectin all those not presenting a contraindication. - To undertake a migration study on all suspected or confirmed cases of onchocerciasis. (Annex 3). - Record all these results in a summary table. t4 Finalization Country 1. I-arge-scale treatment zone (monthly). If the health workers of the district concerned took part in the large-scale treatment. District..... .Health sector Period.. Villages Census population No. treated Vo No. of tablets Observations V1 v2 V3 2. Zone not on a large-scale treatment Period. Villages No. of CASCS No. treated No. of tablets Observations 15 DEVOLUTION OF THE ONCHOCERCI,ASIS CONTROL PROGRAMME IN WEST WEST AFRICA PASSIVE SURVEILI.A,NCE AND TREATMENT FORM FOR FIXED CENTRES Peripho1.ury5 October, 1993. Date Serial No. Family Name & First Name Sex Age From Clinic Labo Weight in Kg Ivermectin dosage Reason for non- treatment Observations CI D CI G