WHO/APOC rapid epidemiological mapping of onchocerciasis (REMO) refinement in Tanzania, May 9-June 9, 2004: mission report

WHo/AFOC RAPID EPTDEMTOLOGTCAL MAPPTNG OF oNcHocE RcrAsrs (REMo) REFr N EMENT rN TANZANTA, MAY9-JUNE9IzO04. MIS$ON REFORT BY Professor B. E. B. Nwoke (W H O/ APOC Tem pora ry Adviser) Department of Animal & Environmental Biology Imo State University Owerri, Nigeria. Tele: +234 83 230 698 E-mail : bebndie@yahoo.com MONDAY, JUNE 7, 2OO4 CONTENT OF REPORT I.O SUMMARY 2.O RESEASON FOR REMO REFINEMENT IN TANZANIA 3.O OBJECTIVES AND METHODS ADOPTED 3.1 Review of REMO maPs 3.2 Training of NOTF team 3.3 Superuision and ParticiPation exercise in field REMO 4.0 RESULT AND DISCUSSION 4.1 Review of REMO maps 4.2 Training of NOTF team 4.3 Field results 5.O REFERENCES 6.0 ACKNOWLEDGEMENTS 7.O APPENDIX 7.1 REMO data 2 {.O SUTTARY WHOIAPOC supported Rapid Epidemiological lf,apping oJ Onchocerciasis (REITO) relinement in Tanzania, May 9 - June 9, 2OO4 to clear the suspected onchocerciasis epidemiological gray areas in the country. As part of capacity building, ten NOTF members were trained on all the lheoreticat and practical aspects of REilO. A tolal ol 128 villages were selected Jor REfflO refinementlupdate irom 8 Regions oJ oJ the country as identiJied by the NOCP Tanzania. VlZz Tanga(|3), Singida(l3), Dodoma(l l), Liwate(l2), Tukuyu(l7), Kigoma(9), Tabora(?3), Kagera(lo), Rukwa(6), Arusha(6), and torogoro(15). The results showed thatt . Some of the selected villages were inaccessible during the field study, especia lly at Liwale Region where the team there observed that the villages selected are in the iaaccessi,ble Sefous Game Reserve. The san e leam also did not examine lhe I I villages sefected from Dodoma Region, the reason, according to the team leader was due to the fact that the area is within the dry trachoma endemic bioctimalic zone which is without breeding sife for Simulium Yectors. . Ol the 78 villages exam inedlupdated, 25(32.10/") ol them had persons positive lor onchocercal nodules. . Gommunity nodule rates in most(76.O"/") oJ the oncho- positive villages were fess than 2O7o(hypo-endemicity). o Five of the villages updated Jrom torogoro Region had nodule rates >2Oy" (meso- and hyperendemicitiy). . Onchocerciasis was absent in all the villages examined in Kigoma, Kagera, Rukwa and Arusha Regions. The epidemiological significance oJ the present result is going to be made clearer when lhe data is integrated into the Atlas-GlS Dy APOC. ., 2.O REASOil FOR RETO REFINETENT IN TANZANIA The approach of African Programme for Onchocerciasis Control (APOC) is to use the communrty - ownership b progressively distribute Mectizan (Ivermectin) in all high risk areas where the inhabitants are potentially at risk of developing severe and disabling dermal, ocular and lymphatic as well as other complications. Epidemiologically, high-risk zones are areas in which onchocerciasis prevalence are meso- and hyper-endemic. Meso-endemic and hyper-endemic areas are those where onchocercal nodule rates are 20-39o/o and greater than 39olo respectively (WHO, t992). Areas at risk of developing severe and disabling complications constitute the zones qualify for Community Directed Treatment with Ivermectin (CDTI) strategy. Ivermectin eliminates skin microfilariae (Alley et al, 1994) hence a large - scale ivermectin disUibution programme (IDP) will not only lead to the reduction of transmissbn but will dramathally reduce morbidity (Remme et al, 1989); Taylor et al, 1990). Also, it has been observed that if this IDP is continued over time, the intensity and incidence of onchocerciasis in man wil! decline to a point where it will no longer be a public health problem. The communities to be treated under the CDTI approach are identified based on Rapid Epidemiological Mapping of Onchocerciasis (REMO) resulb. REMO results for APOC proiects are generated using the WHO approved protocol of Ngoumou & Walsh (1993), WHO (1995) and WHO (1998). The analysis and interpretation of these results by APOC are done using Atlas - Geographical Information System (AUas-GIS) or HealthMapper software. On the basis of standard methodology (WHO, 1998), REMO results are categorizes into three treatment types: (a). Deflnite CDTI area (b). No CDTI area (c). Possible CDTI area a. Definite CDTI areas are zones where REMO results show clearly that onchocerciasis is highly endemic and the disease is a significant public health problem. The ecology and behaviour of Simuliam vectors largely determine the distribution of onchocerciasis and the endemicity levels. One such vector's behaviour is that it has an effecUve flight range, and when seeking blood - meal, it is unlikely to exceed 15km. This means that severely affected villages are almost invariably located within 10 - 15 km of the vector breeding and transmission sites. And since one of the major objectives is to conbol the disease transmission and reduce the burden, the mass IDP will need to be 4 extended to the total population that is actively and potentially involved in disease transmission. To achieve this, villages/zones within 10 - 15km radius of all communities where nodule prevalent rate 20olo and above are also mapped into CDTI definite area - making sure that potentially high risk areas are included. b. The NO CDTI areas are villages where there are no transmissions and or where the Ievels of disease endemicity are bo low to be considered sufficient public health problem b warrant CDTI. c. Possible CDTI zones are areas where REMO exercise was indicated but was not conducted and or where the epidemiological patterns presented by the REMO results are not sufficiently clear. These areas require REMO refinement exercise and or additional rapid epidemiological assessment (REA). During the 9s meeting of Joint Action Forum (JAF) of APOC and the evaluation report of CDTI sustainability programme in Tanzania, it was pointed out that some areas of the county are under possible CDTI zone. And these areas needed REMO refinement; hence APOC sponsored the present exercise. 3.O OBJEGTIVES AND TETHODS ADOPTED FOR THE RETO TISSION IN TANZANIA 3.1 Review, in collaboration with the ilational Onchocerciasis Task Force (NOTF) Tanzania the REMO map. Methods adopted:(a) Briefing and rneeting with WHO,MOH,NOTF(b) Collection and studying of topographical and adminisbative maps(c) Collection and shrdying of the present REMO maps(d) Collection and shrdying of any historical or present epidemiological data that has not been integrated into the REMO map.(e) Update the REMO database based on the information from (c) above.(D Using the maps, and with the advice of the nationals identify areas Areas that require REMO refinemenVupdate 5 3.2 Training of Tanzanian nationals in planning and implementation of REMO refinement erercise. Method adopted:(a) Planning and budgeting, with the nationals the REMO training and field work(b) Preparation of materials for the training and field work(c) Two - day Uaining of nationals on all aspects of REMO exercise.(d) Selection of REMO villages 3.3 Supervision and pailicipation in field REMO erercise. Methods adopted:(a) Preparation and planning of REMO field exercise with NOTF(b) Supervision and active participation in the REMO field study(c) Data entry and analysis(d) Mission repoft and debriefing. 4.O RESULT AND DISGUSSION 4.1 The NOTF provided the current REMO map as well as historical and present epidemiological data. All these were studied with a view to update the REMO data base and identify_ qvhere REMO refinement was needed. At the end, the REMO results of [5 vilhgds from Morogoro arb-a,.which according to NOCP had not been integrated befOre now, Wgre updated. Also, with the help of the national team, areas for REMO refinement were mapped out in the following areas/zones: Tanga, Singida, Dodoma, Liwale Tukuyu, Kigoma, Tabora, Kagera, Rukwa, and Arusha Regions (Table 1). 4.2 Two-day REMO training was organized for the national team. They were exposed to all the theoretica! and practical aspects of REMO exercise. The following NOTF members were trained: 1. Dr. Moshi Ruhiso, Project Coordinator, CDTI Tukuyu-Mbeya 2. John Nganya, Coordinabr, CDTI Kilosa-Morogoro 6 3. Dr.Ramadhan Mbagan, Assistant Medical Officer, Mafinga 4. William Kisoka, Researcher, D'Salaam 5. Dr.Rehma Maggid, Project Coordinator, CDTI Tanga 6. Harrieth Hamis, HKI Project Officer, Tanzania 7. Oscar Kaitaba, NOCP Deputy National Coordinator 8. Dr.Edward Kirumbe, Medical Officer, NOCP Tanzania 9. Dr.W.A.Kabuka, Project Coordinator, Ruvuma CDTI. 10. Dr. Ramadhami Ally Mbagani, Assistant Medical Officer, Iringa Tablel. REMO villages setected/updated during the erercise NOTF FIELD PARTICIPANTS REGION NO OF VILI.AGES SELECTED TEAM LEADER l.TANGA 13 Drs Maggidi & Ally Mbagani; Prof.Nwoke Dr Maggidi 2. SINGIDA 3. DODOMA 13 11 Drs Maggidi & Ally Mbagani; Prof.Nwoke Dr Kirumbi & Harrieth Hamis Dr Maggidi Dr Kirumbi 4. UWALE L2 t7 Dr Kirumbi Harrieth Hamis & Dr Kirumbi & Harrieth Hamis Dr Kirumbi Dr Kirumbi5. TUKUYU 6. KIGOMA 9 Dr Ruhiso & John Nqanya Dr Ruhiso 7. TABORA 13 Dr Kabuka & William Kisoka Dr Kabuka 8. KAGERA 10 Dr Ruhiso & John Nganya Dr Ruhiso 9. RUKWA 10. ARUSHA 6 Dr Kabuka & William Kisoka Dr Kabuka 9 Drs Maggidi & Ally Mbagani; Prof. Nwoke Dr Maggidi 11. MOROGORO 15 Updated REA from Dr BTA Maeqqa TOTAL 128 7 Area refined villagps selecbd Not Access -ible (o/ol Villages examine (e/o) +ve for nodule (o/o) Tlre number and t)b of communities with different nodule rate (o/o) t-90/b 1O-199o 2ll-39o/o above 39olo l.Tanga 13 o(o.o) l3(roo.o) 4 (3o.8) 3 (75.s) o (o.o) I (2s.s)* o (o.o) 2.Singida 13 -l ^r- 3 (23.1) 10 (76.e) 4 (4o.o) 4 (1oo) o (o.o) o (o.o) o (o.o) 3.Dodoma 11 q 1l(roo) o(o.o) o(o.o) o o o o 4.Liwale 12 t2(100) o(o.o) o(o.o) o o o o 5.Tukuyu t7 5(29.O) t2(70.6) 2(16.7) 2(1oo) o(o.o) o(o.o) o(o.o) 6.Kigoma 9 3(33.3) 6(66.7) o(o.o) o(o.o) o(o.o) o(o.o) o(o.o) T.Tabora 13 8(61.5) 5(38.s) I(2O.o) 1(100) o(o.o) o(o.o) o(o.o) S.Kagera 10 3(30.o) 7(70.o) o(o.o) o(o.o) o(o.o) o(o.o) o(o.o) 9.Rulora 5 3(so.o) 3(so.o) o(o.o) o(o.o) o(o.o) o(o.o) o(o.o) lO.Arusha 9 2(22.2) 707.81 o(o.o) o(o.o) o(o.o) o(o.o) o(o.o) 11.1{orogOro l5 o(o.o) 15(10(,.o) t4(e3.3) 5(33.3) 4(26.71 4(25.7) I(6.7) TOTAL 128 Table 2.Summary of REMO refinement in Tanzania, May 9 - Iune 9, 2004 *An updated result fnom Kizara village in Korogwe District 4.3 RETO FIELD RESULTS A tota! of 128 villages were selected for the REMO refinemenVupdating from 8 Regions in Tanzania during the present exercise (Table 1): Tanga(13), Singirla(13), Dodoma(11), Liwale(12), Tukuyu(!7), Kigoma(9), Tabora(13), Kagera(l0), Rukwa(6), Arusha(9) and Morogoro(15). Of this, 50 villages were inaccessible for REMO refinement. In fact, Ul€ team that was scheduled to conduct REMO in Dodoma and Liwale Regions did not access any of the selected villages. According to the team the villages selected from Liwale Region are within the Selous Game Reserye and that Dodoma selected villages are within 8 the dry trachoma endemic bioclimatic zone where there are no Simulium breeding sites. Of the 78 villages where REMO was refined/updated, 25(32.1olo) had person(s) positive for onihocercal nodule (Table 2). Onchocerciasis was absent in all the villages examined in Kigoma(6), Kagera(7), Rukwa(3) and Arusha(7) Regions' Comhunity nodule rateJ of most(76.0o/o) of the oncho-posiive villages were less than 20olo(trypo-endemicity). Five of the villages updated from morogoro Region had nodule rates>20olo (meso- and hyper-endemicity). One village, Kizara in Korogwe D6trht of Tanga Region updated from the CDTI Tanga Coordinator had 20olo nodule rate. Attempt to validate this was hindered by an off-season rain that made the access road inaccessible during the exercise. The inaccessible villages in singida, Tukuyu, Kigoma, Tabora, Kage, Ruhrva and Arusha Regions are unlikely to change the epidemiological pattern of the disease. It is important to note here that wnile working in Manyoni(Singida) Handeni(Tanga) and some parts of Arusha, I observed Urat Ure people in these areas were not aware of iiuer blindness, rather they complain of the problem of trachoma. The epidemiological significance of this REMO refinemenVupdate is going to be made clearer when the data is integrated into Aflas-GIS. 5.O REFERENGES Alley,ES et al(1994). The impact of five years of annual ivermectin Ueatment on skin micrifilarial loads in the onchocerciasis focus of Asubende, Ghana' Trans. Roy. Soc. Ttop. t ed. Hyg.88:581-584 Ngoumou,P & Walsh,JF (1993). A manual of Rapid Epidemiological Mapping of O nc hocerc iasis. TD R /TD E/ O tl C H O / 93.3 W HO Geneva Remme,J et al (1989). A community trail of transmission in the onchocerciasis focus of Asubende. Ghana. 1. Effect on the microfilaria reservoir and the 6.0 AGXNOWLEDGEHENTS I wish to thank APOC Management for the opportunity given to me to be part of the success story of onchocerciasis control in Africa and to WHO Representatives of Tanzania and Nigeria for facilitating this mission. I am grateful to NOCP Coordinator of Tanzania and her team, the NOTF as well as the Regional and District Officers for their exemplary cooperation and assistance during my mission. I sincerety appreciate the contribution of the drivers and the Secretariat to the success of this exercise. To all who conbibuted to this mission I say thank you. Professor B.E.B.Nwoke June 71 2OO4 l0 7.O APPENDIX 7.{ TAELE 3. RESULT OF REilO REFINEUENT tN TANZANIA, MAY9-JUNE9,2OO4 ll J:O UJ\o oo -.1 (,t (/) +. 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