Ad hoc meeting of national coordinators and entomologists (Guinea Bissau and Senegal): OCP, Ouagadougou, 7-9 May 2001

r '*)-r EAcil" 3G) WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFzuQUE DE L'OUEST AD HOC MEETING OF NATIONAL COORDINATORS AND E,NTOMOLOGISTS (Guiriea Brssau and Senegal) OCP, Ouagadougou, 7 -9 May 2001 OCP/EAC22.3C 23 I. INTRODUCTION The ad hoc meeting between OCP on the one hand, and Guinea Bissau and Senegal on the other, was held from 7 to 11 May 2001 at the headquarters of the former in Ouagadougou to ascertain the progress of onchocerciasis control activities. The aim of the meeting was to raise residual issues in order to find solutions that could enable the gains of onchocerciasis control to be maintained. 2. OPENING The opening ceremony came off on 7 May 2000 at 15h 30, and was presided over by Dr. L. Yam6ogo Chief VCU, since the Director of OCP was absent. Present at the meeting were Dr. Akpoboua, Dr. Soumbey and Dr. Siamevi, with the national Coordinators of the two countries mentioned above (Drs. Antonio Tamba Nahque and Lamine Diawara). All present recognised the irnportance of this meeting, especially at this critical time of the end of the Programme. The various speakers touched on the particular attention that must be accorded the various adjustments that needed to be discussed during the rneeting. The two national Coordinators at the meeting were to give an update on the epidemiological, entomological and administrative situations, as well as the challenges to be taken up by the end of 2002. MAIN ISSUES TO BE DISCUSSED (Subjects of common interest and specific problems) 3.I GUINEA BISSAU 3.1 . I Epidemiolo sical results. The last evaluations in the rnajor basins (Rio Gebu and Rio Corubal) date back to 1997. These evaluations had to do with 11 r,illagr:s on the Rio Geba, and 15 villages in that of the basin of Rio Corubal. The results of these evaluations indicated a prevalence on the Rio Geba, ranging from 0.5ohrn Tabassay to l.lYo in the village of Meta Seidi. On the Rio Corubal the prevalence vary between 0.9 and I2.2% in the 8 villages where positives were found. Due to the fact that no treatment has been carried out in this basin since this period, it is necessary to conduct epidemiological evaluations in these 2 basins by the end of OCP. In this direction, 38 villages will be evaluated effective May 2001. The results of these evaluations will be interesting fi'om the scientific viewpoint, given that they would reflect the situation after 9 years of continuous treatment. A Letter of Agreement has been signed in this connection, and measures are being taken to facilitate the implernentation of this evaluation. 3.1,.2 lmplementation of CDTI Since the cessation of mass campaigns, no treatment with ivermectin has been carried out in Guinea-Bissa'r (except the training of community distributors), becruse of the social and political disturbances, and also meningitis and cholera outbreaks. The drsturbances coincided with the beginning of CDTI implementation in May 1997 , by the training of nurses and technicians of health centres. The training took place in Gabu, with 36 technicians and nurses from health centres from the Gabu region and 8 fiom the Bafata region. These health workers that were trained, in turn, 3trained community distributors (CD) during the same period. These CDs carried out their first treatment in 104 villages during the practical fieldwork of their training. We were not able to undertake any other activity since then, neither retraining nor ordering of ivermectin etc.. The actions to be undertaken will depend on the results of epidemiological evaluations that will take place in May/June 2001. We will take advantage of the evaluations in the villages to train the CDs, who will continue treatment. Ivermectin needs will be covered by OCP. CDTI will be extended later to villages which, usually, were treated by mobile teams, and may also be extended to other villages. Responses to followins issues I How to arouse and sustain the interest of health personnel (especially at the district level) for the continuous management of onchocerciasis control activities? The appointment of the Gabu Regional Directol of Health as deputy Coordinator will help to take into accouut oncho control activities in the 2 affected regions (Gabu and Bafata). These activities will be integrated into the minimum package of activities. Concrete actions planned for ensuring the sustainability of distribution (incentives and ownership of CDTI by communities, incentives of community distributors, etc..) Strengthening supervision of CDs at the begimring of activity implementation. The rnhabitants, through the management comrnittees u,iil as usual, give incentives for these CDs. These CDs will be accorded special attention by doctors for their own health care, as well as that of their farnilies. 3. Measures that are actually taken or envisaged for the integration and decentralisation and of CDTI activities, as well as epidemiological and entomological surveillance. Training of technicians on evaluation techniques (skin snip, reading, census etc...), Special training of a physician/entomologist to train technicians so as to meet country needs. This entomologist has already been identified, and will undergo training at Odienne in August 2001. 4. Preparedness of decentralised teams (training, availability, incentives, equipment). How to make means available to these teams for activity implementation? Training of decentralised teams has already started. There is need to retrain them, since they have not undeftaken any activities since 1997. Several staff members who had already undergone training have deserted, thus reducing the number of technicians on the field. Incentives for health personnel have been a problem due to the difficult economic situation of the country (low salaries, difhcult working conditions etc. . .). It has been planned to equip the health structures under the National Health Development Plan. This plan is yet to be financed. The re-launching of the Bamako Initiative will contribute to ) 4fundrng onchocerciasis control in an integrated health system framework (the World Bank is currently supporling this initiative to be put in place). Regular data collection, proper management at operational, intermediate and central levels for appropriate decision-making (capacity for analysis/action). There is need to train the staff of these various levels. Re-starting CDTI and epidemiological surveillance activities will facilitate the data management system. Training/retraining of health workers, supervision/monitoring, actual consideration of oncho control activities in plans of action. Sarne as for item No. 5 7. Sources/lnechanisms of financing Oncho activities after OCP The Govemment of Guinea-Bissau, under the National Health Development Plan has already drawr-r up and which takes all health problerns into account. 8. Ivermectin orders/supplies (peripheral, regional and central levels) We are waiting for the re-stafl of activities ir-r 2001 in order to plan the ordering of our tablet neecis fron-r MDP for treatment in 2003. OCP will continue to ensure drug availability for this year eud for 2002. 9 Current and potential partners that may support countries to continue rvith activities. Apart from the State and OCP, Guinea Bissau does not have any other support. lt is therefore necessary to look for other sources of funding, especially among NGOs. 3. 1 . -l Study of the impact of ivermectin on transmission for 2001 and 2002 No such study has been conducted in Guinea-Bissau since the training of national Entomologists. Proposals were made to OCP for the first study to be conducted in July 2001. The Letter of Agreement is being reviewed for signature. 3.2 SENEGAL 3.2.1. Epidemioloeical results in 2000 These results were presented at the last JPC in Yaounde. The results of the epidemiological evaluations of villages on the Garnbia, Falerne and tlie Koila Kabe in the 4 health districts of the onchocerciasis zone of Senegal. On the whole, 20 villages were evaluated, with an average prevalence rate of 3.3o , varying between 0.6 and 8.3%. Tn these 20 villages, 119 persons were four-r., to be infected in 19 villages, out the 3595 persons th-t underwent skin snip. This means the parasrte reservoir is present and that efforts have to be r;doubled. During discussions with CPET, the possibility of envisaging the elimination of onchocerciasis in Senegal, through the ,ntensifying of current CDTI efforts was obvious. 5 6 5For 2001, epidemiological evaluations will take place in 31 villages, distributed over the various basils. The evaluations started since i9 April2001 and will continue until6 June 2001. The implementation of evaluation activities is entirely taken care of by the national team based at Tarnbacounda, in close collaboration with technicians of district teams (lab. Technicians for underlaking skin snip tests and reading snip results, PHC supervisor for census activities). The district chief medicil officers participate with the other members of the evaluation team in sensitisation activities in the villages, as well as in the parallel evaluation of the quality of CDTI implementation. These evaluation activities have become routine ones in the districts. Marntaining a single evaluation team, based tn Tambacounda and working itr close collaboration with the district teams is the option chosen as part of the decentralisation of epi clenr olo gical survei llance. The new magnifying glass given to the national teant was requested by the national Coorcllator, since the one in use dates back to the beginning of activities in 1987. What remains to be done is to train doctors and supervisors in the area of epidemiological surveillance of onchocerciasis with regard to decision-making. An application must be made to OCP in this direction for financing, after discussions have already taken place with CPET. 3.2.2 Study of the impact of ivermectin oD transnrission 11 1999 and 2000, studies of the impact of ivermectin on transmission were carried out at the catchipg poilt of Mako, in collaboration with the molecular biology laboratory of OCP. This catching point proved to be less productive in the course of the 2 years of study. We were not able to assemble the 8,000 blackflies required per year. These studies were, however, very infonr-rative. In fact, we realised the commitment of communities through the village captors, as well as the support community leaders gave them. In addition, we were able to put in place, during the second year, a system for dispatching flies to the laboratory by the EMS (express mail service), which gave us satisfactory services. This channel will henceforth be used in future. 3.2.3 Implementation of CDTI CDTI was launched in June 1998 in Kedougou during a training session which brought together trainers (Regional and district Chief medical officers, supervisors of PHC), as well as parlners (Prefect, sub-prefect, head of rural community, local journalists). This workshop, which was financed entirely by OCP, was attended by the CPET and a consultant of OCP. It was appreciated by all the participants, and gave a clear vision right from the beginning of CDTI. ResDonses to the followins issues: 1 How to arouse and sustain the interest of health personnel (especially at district tevel) for the continuous management of onchocerciasis control activities? To do this, we undertook several training/retrair-ring sessions, as well as workshops, which l-relped to share with tlie various health workers a clear vision of oncho control. 6The training sessions the personuel received were very rnotivating and helped them to focus on the programme. Supervision of activities by level also contributed to strengthen their capacities, especially of health centre chief nurses, around whom the entire CDTI device is built. The participation of the Coordinator in some coordination meetings of the district (which bring together, under the direction of the Chief district medical officer, all chief of health centre nurses) improved the output of the programme. The support of the NGO named OPC to the Chief nurses contributed to enhance their motivation (fuel for supervision, motorbike ride sometimes, treatment allowance per village etc..) Concrete actions planned for ensuring the sustainability of distribution (incentives and ovl'nership of CDTI by communities, incentives for community distributors, etc...) En suring permanent avai I abrlity o f ivermectin. Training CDs by chief nurses. Advocacy with community leaders (chairpersons of health committees, village chiefs etc...) to solicit support for the CDs. Measures actually taken or envisaged for the integration and decentralisation of CDTI activities, as well as epidemiological and entomological surveillance. CDTI management tools are integrated into the information system for purposes of management (national MIS), and CDTI data are taken into account during semester rnonitoring at the health post level. training of teclurical tearns (laboratory technicians and PHC superi,isor) in epidemiological surveillance; participation of the latter in annual epidemiological evaluation activities; Onchocerciasis control taken into account in a module being designed by the national Coordinator of surveillance (who is a former Coordinator delegate of Oncho); Training of doctors is scheduled forby the end of 2001 on epidemiological surveillance for decision-making. Technical assistance is solicited from PET and seems to have been obtained. Providing a budget line item under the Integrated Health Development Plan for evaluation activities and an impact study in the 2001 and 2002 budget. 4. Preparedness of decentralised teams (training, availability, incentives, equipment). How to put means at the disposal of these teams for activity implementation? Under CDTI, decentralised teams totally integrated oncho control activities into other activities of disease control and epidemiological surveillance Emphasis is placed on the model district [eam, on the supervision of CDs and on training/rutraining of chief nurses, given the desertio,r of staff. 2 3 1With respect to epidemiological evaluations, we opted for a single team based at Tambacounda, which works in close collaboration with district teams during evaluations. The level of equipment of the team is quite good presently (especially Holth forceps). The magnifuing glass, which is wom out, needs to be replaced. A request has been made to the CPET and we hope it would be procured under the PDIS budget, if need be. Regular collection, proper management of data at operational intermediate and central levels, for appropriate decision-making (capacity for analysis/action) CDTI data management has become part of the routine. Problems however crop up when it comes to village reporting, especially when the CD is illiterate. The management of evaluation data is yet to be integrated. This will be done after the training of the 2 technicians we have requested PET to offer. The 2 technicians might come to Ouagadougou with forms at the end of the evaluation early June 2001. From this tirne on, we will be in a position to easily manage by ourselves the various data in the data banks of OCP. 6. Trainingiretraining of health workers, supervision/monitoring, actual consideration of oncho activities in plans of action. Trair-ring/retraining sessior-rs were conducted betu,een 1998 and 2000. We are rather going to put emphasis on the follow-up of training, especially in the area of CDTI. Training of CDs is ongoing in the districts with funding from PDIS and PLCME where the Oncho programme is housed. We are waiting for training modules which are being finalised at OCP. 7. Sources/mechanisms of linancing for oncho activities after OCP The State of Senegal and OPC (NGO) The greater part of funding will come through annual Operational Plans (OP) under a general planning system within the Ministry of health. 8. Ivermectin supply/order (central, regional, peripheral levels) Senegal, for the past 4 years has been placing Ivermectin orders directly with MDP. We met with community tax issues (ECOWAS, UEMOA), which delayed the delivery of drugs at all levels. It is necessary that the WHO representation in Dakar, which has some waiver privileges get involved in the ordering of drugs. 9 Current and potential partners that could support countries to continue with activities. We are currently being assisted by OCP and OPC in the implementation of activities. In the post-OCP period, we are likely to still enjoy the support of this NGO (OPC). The Oncho control activities will, naturally continue to get assistan;e from PDIS, under the global financing of the health sector. 5 4. 8 MEETING WITH THE ADMINISTRATION A meeting was organised between the administration and Coordinators of Guinea-Bissau and Senegal, in order to review the various existing problems and find solutions to them. 4.1 Guinea Bissau The logistics problems and those relating to bank accounts were raised. With regard to vehicles, only the Coordinator's is in good running state. Another vehicle could be repaired to make it road-wor1hy. There are, however, 2 vehicles in Gabu that are wrecked, and which need expert valuation so that a decision could be made on them. The various bank accounts that existed and which were provisioned, prior to the outbreak of conflicts, r-nust be reviewed for a decisron to be made on them. 4.2 Senegal Logistics-related problems were raised, and it was agreed once again to assign two vehicles to the national teanr. The monthly administrative liaison needs to be irnproved to ensure better output The establisliment of the Letter of Agreement for administrative supporl and supporl for supelvi.ion were also raised. Actions are undenvay between OCP and the National coordinatiorr. 5. CONCLUSIONS AND RECOMN{ENDATIONS 5.1 Guinea Bissau Restart of evaluation activities in Mav/June 2001 (NC, MOil) Restart of CDTI activities by end of 2001 (NC, MOH) 5.2 Senegal Continuation of current efforts (NC, MOH) Easing imporlation of ivermectin by WHO representation Continued suppofi of PDIS to National Oncho control Programme under the Health Sector Global funding. Training of doctors and supen,isors in 2001 in epidemiological surveillance, with a vie'uv to rnaking decisions. Continuatior-r of technical, matenal and financial assistance (OCP) t , , a.