Final report of the consultantship from May 1985 to April 1986

ONGN{ISATI,ON MONDIALE,DE LA SN{TEiiORLD I1EALTH ORGANIZATION FINAL REPORT OF THE CONSULTANTSiIIP FROI,I MAY 1985 TO APRIL 1986 EPIDE}'IIOLOGICAL EVALUATION UNIT oNCHOCERCIASISCONTR0LPR0GRAMMEINTHEvoLTARIVER.BASINAREA DR. MANUEL BAYONA CELIS EPIDE}'IIOLOGIST ..4 CONTENIS 1. INTRODUCTION 2-. PURPOSE OF THE CONSULTANTSIIIP 3. ACTIVITIES CARRIED OUT 4. OTHER ACTIVITIES 5. CONCLUSIONS 6. RECOMENDATIONS 7. REFERENCES 8. ACKNOWLEDGEMENTS Y. APPENDIX Pag I 3 3 4 7 10 L2 l3 Page 1 T. INTRODUCTION fhe savanna area of rhe Vo1ta River Basin, in WesE Afrlca, has been one of the worsc endemic onchocerciasis zones of the world (l)' Ar the beglnning of the Onchocerciasis Control Programme (oCP) lt was{istimaEed that J.,.. . million of the ten mitlion inhabitants of the OCP ,trea were infecEed, and more Ehan I00 000 of them were blind or had serious visual impairrnent,. In some hlghly exposed hyperendemic villages about 502 prevalence of blindness was found ln adults over 30 years of age-' These victius were at the peak of thelr productive lives. It was also known Ehat blind persons suffer 13 to 15 years reductlon in life exPectancy (I)' The OCP area originally covered endemic areas of seven west afrlcan counErles: Burkina Faso, I'la1i, Ivory Coast, Ghana, Togo, Benln, and Nlger (Appendix)' AE present. this area has increrased covering endemlc areas of 'Gulneet Guinee Bissau, and Sierra Leone (Appendix) were Ereatment wit'h larvlcides will start Ehis year. lnhabiEanEs of the fertlle valleys flanking the river were afrald of "River Blindness" and migrated to poorer lands far from the rivers which were Ehen over-cultivated and failed to provide adequate means of subsistence' I, was esEimated before Ehe start of OCP oPerat.ions Ehat more than 65 000 km- of che land ln Ehe river valleys was abandoned by the occupants due to the high risk of disease. It was calculated that about one mlllion people .orrta evenEually be settled in these onchocerclasis endemlc areas, if the Eransmlssion of the lnfection could be brought under control (I). In the absence of suitable drug for mass Ereat,ment, OCP has adopted vecEor control in order to interrupE transmisslon and protect the inltial populaEion and those born afEer Ehe start of cont,rol fron new infeetlons' Hor.r.r, not,hing could be done against adult worms whlch were a result of the pre-cont.rol lnfecti.ons. These worms were and still are producing microfilariae maintaining a reservolr of lnfecElon whlch could cause transmlssion to recommence ln case of return of the vector' For Ehls reason, vector cont.rol has Eo be continued for a sufflciently long period ro allow the reservoir of infect,lon to die out. or fall to an inslgnificant level following natural death of adult worms. Based on lnlEial estluat.es on longevigy of adult worms vector conErol was planned to lasg for 20 years(I). Now iE is known that 15 years may be enough (2)' 'lhe epidemiological evaluation unlE (npf) of OCP is responsible for the evaluaEion of the impact of vector control on dj-sease transmisslon and the srucly of che decline of Ehe disease in initlalty infecced populatlons (3). b'or Ehe field work Eo collect all necessary dat.a for epidemlological eva}uation two parasitological and two ophthalmologlcal teams are available. The personnel ine.luded ln eac.h team is as follows. Parasitological Team. t Physic-ian (EPidemiologlst) 2 ParasitologY techniclans 2 Census clerks I Assistanr for assessment of weight, height, and visual aeulEy t;hthalmologic-a1 Team. I Ophthalmologist I Nurse spee-ialized in ophthalmology 2 AssisEants and decailed epideuiological evaluatlonsi'tp ] L' are carrled ouE ln the Page 2 field.Thepurpose"oftheslnpleevaluaEiol.'".osEudytheparasite reservolr by assessing prur.t"l"e and fot"t'"iiy- oflIniecE{on (i'e' ' microfttarr.r roli]-ii'^in.'"*r">l''""a vtsual r'p"it'""t and bllndness bv a visual acuit,Y tesE' Derailed evaluarlon Ls carried-out to learn-abouE the'flt9q'aee-under vector c.onrrot. Thls Eype of ur.ftrlifoi io"frra." io addltldu Eo the data corlecred in simple ".,rr,rliiio",-- "o'prti" -opitntr'ologlcal and tlermarologlcal u*Irilu.ron". ti"-."aitl.ies toi-eattr lf ttt""" examlnaEions rre as follows' irnrple EvaluaElon' . Census . Bloodless biopsy in both illac crests (skln snips) for examination . VisuaI acultY examlnat'l-on' ,,ecai1ed Evaluation' parasttologlcal . Census r/o1'{n on{oe) for parasltoLogteal . Bloodless biopsy ln both lllac creBts (skln sn1p"6) ,f r l. l l examination . I)ermatological examinaElon . Visual aculEY examlnatl-on' . Opt anrfmological examinatlon Page 3 2. PURPOSE OT THE CONSULTANTSHIP The purpose of rhe consultantship was to partlclPate ln the epldenlologlcal e,aluarion for both simple "oa detalled epidemiologlcal surveys and ,.ollaboraEe wirh the Statistical Analysts Unit (STAT) ln the dat'a analyels of epidemiological data. ln I I vtllages located ln Burklna Faso persons were examlned parasitlogically 3. ACTIVITIES CARRIED OUT l. i. t-ield l,Jork Activities parJ-iclpa+ion.,-as-,a Physician (rnedical of f icer) ln charge of a team for epidemltlogleal evaluaiion ln sirople and detalled sufveys. 3.1.1. SimPIe Evaluation a. Supervision of personnel durlng fleld work' b. Medical e-onsulEation, and treatment of diseases other Ehan onchocerciasls. These act.iviEles \./ere carried out ln 13 villages located in Burklna Faso, MaIi, Ivory Coast, and Ghana. A total of 4008 persons were -€xamlned paraslEologlcally, and tlros9 wlth dlseases other than onchocerclasis were i1"o "*"rined cllnicallY (4,5,6). 3.1.2. Detailed Evaluation a.upervlsion of Ehe parasitological team personnel durlng fteld work' b. Deruatological examinatlon, searching and counting onchocercal nodules' and recordtng diseases other than onchocerciasls' cr I'ledical consultati-on and treaEment of diseases other than onchocerciasis. These act.lvlt.ies hrere carrled out and Ivory Coast. A total of 2735 and ellnicaIly (5,7 ). 3.2. Data AnalYsis 3.2.I. PrelimlnarY Data AnalYsls AfEer every fleld work trlp a Sullmary of flndlngs was prepared wlth the raw data includlng crude prevalence rate of infection, crude asaessment of the inEenslty of the infection ln patlenEs with-skln sntp poslEive, and ln totat persons examlned ln-the .rittrg" (4151617). Further data analysls ls being carried out ln the cornputer facillt'les Ehe Programme' 3.?-.2. Data Entry The epideniotogical data entry plan for comPufer analysls was elaborated ln collaboration with STAT. 4. OTHER ACTIVITIES 4.I. Assessmenr of Quality Control for Data Collection Qualitycont,rolofdaEacollectlonfortheeensus,parasitologicaland clinical examinatlons was t"tifta ouE' Inter-observer vari tlon I e.arried out for thaE PurPose' 4. I. I. Assessment of quality control for census data collectlon was c.arried ouE. A Eoral ot 25r ;;;;;", ,0"r" lnterviewed twlce for thaE purpose (8). 4.L.Z.ASSessmentofquallty-controlforpasitologlcalexaminatlonwas carried ouE. i"-aoiri of. 257 skln snips were us d for thar purpose' rnter-observer variaEion on the g6'-rir,rau attd. 24 hour readlngs was assessed +.I.3.Assessmentofqualitycontrolforclinicalexamlnationswascarrled ouE. Inter and Intra-obsutt"t vartatlon *"t" assessed' For Ehe inter-observer variation a Eotal of 85 Patlents were lncluded for dermaE.oroglcal .*"*ir,raio., a.,a-oz2 eyes for- ophEhalmologlcal examlnatlon (9). For ir,.t"]ou"erver variatlon ig pat'ienis were tncluded for the demarological examination (7)' 4.2. I'tanuat of Field Work Procedures' lneollaboratj-onwithatlEPlstaffitwaspossibletolntegrateafirst ,lrafr of rhe manual of truia-wort p.o".a,ri"s for EPr' A detailed .lesc'ri-pEionofeachfiela*o,r.'-".truity",,athematerlalsandequiprnenE rlecessary to carry them ouE ""tt i""rudei in the manuat (10)' ,.3. Summary RePorE on the Objectives and Tasks of !i tr I0 Years of Vector Control' rapootlehorBbEoEiEriuhieillaftofelBioyelrstaffveEtEPlcantlr6tATryaa ptelinitady r-*is report ,,,**"ti'us th; oU:""if'"s and tasks of EPI' A au,mary and a ,iiscussion on serect,ed epidemioiogr".r findlngs after 10 years of vector ,-ontrol is includu6 (lI)' 4.4. Report on the workshop on Epldemiology' lncollaborationwit'hDr.oumarBa,EPlprofesslonalstaff,partlcipants from ,CP, .r,a ,,o,']OCp invlted expertst a rePort on the workshop on epidemiology was elaboraEed. The-rlport w111 be presented. and discuesed duJing 4er-r .qge4ng-glltrg OcP n*p"tt Advlsory comitee (EAC)' Thl-s report includes a summary of alt toplcs tirat were dlscussed' major conclusions and recommendations ii-ttt *ut" *"i" during the workshop (12)' Page 4 EPI and the SituaElon 4.5. Participation in Ehe collection of baseline epidemiological dat'a for the Farako on a limited area was carri'ed out' prellminarY informatlon and riojecc on vector rePoPulatlon Page 5 4.5.I.Avisit'totheOCPsectorinBoboDioulasso,BurklnaFaso-Eo interyiew l"1r PangaleL, chief of aerial oPeratlons and Dr' Agoua' chtef of the OCP sector Ias carried out' -i"iot*tiloo abouE Ehe locat'ion of vector breedingsltes,VCUcatchlngpoints,vlllages,andaccessibllltyofall villages in rhe Farako-sikasso ,i"t -r." obialned (i3)' Thls informaEion was also used E,o plan a fleld lrip to collect Inore sPeclflc data ln the area. 4.5.2.AfieldtripwascarriedoutEocollectspeciflcinformatlonabout exacE locarion, "ir! ""a a""esibtliiy tf all vlllages tn Ehe Farako-Slkasso area in MalI ( I4). This inforrnatlon was used Eo plan a preliminary baseline epidemiological evaluaElon of the area' 4.5.3.AfieldErlpEocollecEprellmlnarybaseltneepldeniologlcal infrmaEion was carried ouE ln a nunblr of vlllages ln the Farako-Slkasso area. simple evaluation surveys followlng ocP standard procedures were carried out (4). 4.5.4.AprellminaryproposalforEheFarakoProjectwaselaboratedln collaboraEion with EpI professional sEaff and Dr. nlrnard Phllippon', chief ofVCU.Thlsproposalcontalnstheobject,lvesandspeclflcalmsofthe project as well as , "rrr*"ry- oi Ehe speciflc matertal, meEhods and activitles to be carrled out (15)' Page 6 5. CONCLUSIONS TheconsultantshipcarriedouEfrom5},lay1985to5Aprll1986tooCPwasa very importanE prtfessional experlence. Interesting and useful actlvlt'les were underEaken tt OCp headquarters and ln the fleld' ItwasagreatopportunltytglearnaboutOCPprocedures''results'and applied research -!'"pu"irUi thos;-;f EPI. Thls source of information Ls invaluableforresearchinonchocerclasis.}'loreover,newreallsticldeas for the control of onchocerciasis in I'lexlco have been generated from ocP work and research' ThepotenEialuseoflvermect'in,handapplicatlonoflarvlcideslnllnited rreas, monitoring of ,vector '"pt"r"" 'Ly. ustng the Bellec trap' new :pidemiological rurveillance ,L'at oa", "rrd quatity control -nethods f or .-i.idemiological dara eollect.ion] ai"-"or" of itre tt"' tot""pEs fron OCP Ehat '.rn be applied i"-ot'tt'o"erciasls research projects ln I'lexlco' . .,reliminaryresulEsafterl0yearsofvectorcontrolfrouEPl(1I)showa .,bZ a'erag" ,.a.r"ilon in the rrrt".r"rty of infeetion, 402 average reductlon i,i rhe pr"u.r"i"u-."."r, and der"-- reluctlon r"-it'" nuuber of live adult :iLariae per nodule. I am very-iipr""""d by-these excel'lent resulEs of ocP i r.i regard Eo control of tr"r,"""ior, of tnf ection by keepJ-ng a unlque urrr()rnologicar ef f ort and intenslve epldernlological evaluatlOn' some recommendations to EPI are uot lncluded ln thls rePort because they werediscussedintheworkshoponepideniologyheldat.ocrtreadquarEersin .lanuarylgs6.ThisrePorEonlylncludesrecommendaEionsnot,dlscussed fullY during the workshoP' Page 7 6. RECOMI"IENDATIONS 6. t. Addttional Work and Research Due Eo tiue limitations and the workl0ad for EPI durlng 1986-87 conslderatlon should be given to recruit an epldemlologlst (1'e' a physician with a doctoral degree in epideruiology) able t'o handle epidemlologi-ca1 methodology on ".rlt.y", .e".ir.h, and proper data analysis' Addltlonally, short-term consultantshlps Eo carry out some of the addltional work and research are needed. This ls especlaly lmPortant nol'' that EPI has identlfled addltlonal priorltles such as aasesstrent of the reservoir, importance of migraEl-on, and potenEial use of Ivermectin ln addition to Ehe definitlon and the piannlng of the acElvltles to be carried out ln the Western Zone of the frogianrne tn collaboratlon with VCU and ECO' Some of t.he addirional work to be carried out as soon as posslble and the suggested consult.ants or potentlsources for consulEant's are: 6.1.1. To flnd a skin snip procedure to assess resldual lnfectlon as a source of Eransmlsslon. For Ehls purpose it ls necessary first Eo Cetermine the sensitivlty needed. one way to proceed ls to colDpare xenodiagnosis wlt,h the highest sensltlve parasltological test such as incubat.lon of up to 12 skln snlps for 24 hours ln tlssue eulture nedla and/or collagenase dfgestlon of ,p to 12 skln,snips. Later, th9 comparlson of several skin snif, pro_cedures to be used on a large scale wlth the highest sensitlve t""i orfff help to deEermlne which skln snlp procedure has enough sensElEvity to asaess residual infectlon as a source of transmission. several authors have published work on Ehis matter. I would suggest that Dr. H. Schulz-Key and Dr. B.O.L. Duke be eonsulted' 6.1.?-. Residual inf ectlon as a source of t.ranst[lsslon and the early deEecEion of new infections uay noE be Pract,icl or feasible by using parasitological tests on a large scale. The evaluation of the applicatlon r)f a YlazzoELL patch Eest was suggest,ed durlng the EPI workshop for those purposes. Follwoing a simit"r piotocol as the one for selectlon of best pu.u"itological test a l{azzotli paEch t.est may be tested' A control group free of onchoe-erciasj-s has to be included to determine false posit'lve raEe of the Eest. \mong auEhors wit.h experience in t.opic applicatlon of DEC I would suggest iriat Dr. H.R. Taylor and Dr. I*I.E. Langham at the wiluer Insitute' Johns LIr>pkins HosplEaI, Balti.ruore, Iularyland, U'S'A' be consulted' n. I . l. During the workshop an agreement was reached Ehat for the ,;arasiEological examinat.lon a single readlng at 24 hours would guarantee rrigh percentage of emergence of microfilariae and would slnpllfy fleld work .ind implementation of quallty control procedures. It was suggested to .rvaluate the poEential 'benefit of uslng l-nverEenlcroecoPes, plasE'ic ,rierotiEration lrry" with a flat bottom and a double punch if more than two 'iopsies have to be Eaken. \l\)re than 8 years of experience on the use of Ehese Eechnlques used routinely in several research Projects has been accuoulated ln the i;arasiEology laboratory of The Centre of Ecological Research of South-EasE ttexic-o (CIE-S), located in San Cristobal de las Casas, Chlapas, I"lexlco' r, " 1.4. Computation of samPle should be c.arried ouE as soon size and sarnpling of lndlcator vlllages as a basellne docuuent and maps wlth a1I Page 8 rlecessaryinformationforthesaropringprocessarePreparedfort'hewestern \rea of the Programme' Tofi.ndStaEist'icianswithexperlencelnaurveysamPllnglnruralareasit would be suggesced to consult- Dr. Allan Rosa, aE-;h; Scf,Ool of llyglene and public. Healrh, T;; -iot.," tropkrns ;;i;;r"iy, and Dr' Ilector Ilernandez' at t-he of f ices of ft'l S"tt"tary of llealth ln Mexlco ClEy' '.I.S.Analysisofcllnicaldata.Detaileddataanalyslsofallcllnlcal ,.iata by using multiple adjustmeni pro"ed,,,""'tn,,,. be cairled out. }lulrlple t,.,gisric. ..rr""]illl- ""i"ival dlta analysls,'-and proportlonal hazards jraEisiEicat proceduies should ;-;;";ieeita iot thls purpoae (L6'L7 'I8)' :.urrher analysis should be carried out l-n regard to lncidenee of 'lnfectlon in children born afEer startin! or ocp. A9" taj""t"a incldence rates aod rire use of person-years as a i"rro*fr,"tor ior "i'"t' t"t"s must be lncLuded ri9). ijonsiderationshouldbegiventothelncluslonofacomparlsongroupto a^alyse clinical i"r. forrifUuafiafy. I ""*ple of f ur communitles had been surveyedinthesouthernextensionofoCParealnlgTglnordertoobtaln oaseline data (detailed t'"f"tifo") for f"'ttt"t f llolu-up by the epidemlological ".r"i,r.tron uni!. However, .'."ao' control ln the southern exE-e-nsio-4--ui-I-L---not slart .U"iot" 1987: Cive" the f act that theae communi_t,1." ,.r"t-be "*r.rrrat.d ;;;l; before vector control operatlonE sEart' and keeping in rnind rhar ,.""il"iar. ara. for-it"' can also be used for comparlson later, during vect;; "orrarol, these conmunitles can serve as cont.rol in order to assess --o""t'o"ttt"f ft"fo''" lncldence raLes .end incidene.e paEEerns by "o.rao"tlrrg'--, second epiderolological survey in r 986-87 . It should be ned that the eommunities outslde the current' OCP area (sourhern Area) should r""".rir" Ehe baselrr,e lpraenlologtcal patEerns of E.he coumunit'ies to be selecttd tot couparison in t'he Eastern Area of OCP' It is known that onchocerclasis-is mtider ln the forest and intermediate zones (Southern Area) compared wlth savanna ";;t;;;tlasls (EasEern Area) wiEh slmlrar levels of lnrenrl;;-- "i tnfectron' Therefore' durlng data analysls a correctlon fact,or basld on cross-sectional couparisons beEween inrensity or ir,i""iio" .rra oo.trocercal lesions in both forest and savanna zones should be used, and the correct, rot.'p'"t".io,, of the resuits should underllne thls liniEaEion' ExperEsindataanalyslsfor.prospectlvestudieslneptdernlologythatnBay be constdered are: Dr. Ronald S.ooi.*y"r, Df.-;ily" W' i<trnUatl and Dr' Earl Diamond.TheEhreeofEhemfio'tt't-School-oiitygieneandPubllcHealth' The Johns Hopkins unlversiry.'-;;. oiarond h;; t;;;tlence ln data analysls forstudleslnonchocerclasiswortrngwrtnDr.Buckandrecentlyasan advisor to Dr. BaYona' 6.2. Problems of Couptianee or Non-responae' lnoCPlongltudlnalobservationsareneeded.Theuseofdatawlthmoderate t,olargenon.resPonseralesshouldpresumethatthenon-respondersare simllart,othoseincluded'whlchnayormaynoEbetrue'Therefore'the import'antquest,ionlnthtsregardlshowtoanalysethedataorbet'Eerhow to interp.ur a"ia ,rtt hlgh non-response ."1""' survlv l dat'a analysls technique" "toria be conslder.a "" tirey handle non-resPonse wlth dlfferent' approaehes and nay help to evaluaEe accurat;'y if rnajoi Uft" exlsts in the irrterpretatlon of the 6316 (18)' Intheeventoflackofcooperationfrom.anindividualoEherinformat,lon rnay be nerptir in ludgrng-wh;'r;;;- or noE the non-resPonse group dlffers ln some respeeE from the respo.ri..". rD partrcuiar-indirect informaEion from Page 9 relatlves, nelghbqrs or frlends about bllndness, obvlouF.. corneal leslons and reasons for non-response should be used. t'aier, during data analySls' prevloui flndings in all facrol"- ,rna", study stlputd'ue found fron the non-resPonsegrouptobeconparedwlEhtherespondelrtBeirehasage'aex, prevaleuce of ilte.tron, rr.t.i}ty- of tnf eltlon' lanq prevalence of onehocercal leslons, since they heip to assess if lupoigant dlfferencee exlsts between these two grouPsr rn additlon to Ehe cornparlson of the ftndings between '-non-response and respondents groups iL l.s reconm",,aua to make an inEeT'lY:- effort ln a subsauple of nonlrespondents -io-g"t as much' lnformatLon as possible by vislring theu ri rt.i, too""nori"."-itr" nay help'ln estlinatlng the extent of blas aluong oo"]t"tpondents ln relatlon to respondents' Inordert.olmprovethecooperatl-onthefollowlnglssuggeated' A11 lnhabltants of everf- vlllage should be included whenever possible whether or noE they belong t.o the follow-up sample' Not only has thls been shownEoimproveresponqebutalsogeneratesinfornatlouaboutimportance ofmlgratlonlnregardtoprevalenceandlntensltyoflnfecElon. treatnent for sLck people ls a good '9?n" -t9 lmnrove continge. Addltl-onaify, tt't to"iloe dlstributlon of hromen and chlldr"n tefis to lmprove re'ponse from the An imporEant proport,lon of children.are not attracted by-itt" roedical care or vitamlnes. i*""t" "oa "ootres as a glft for every chlld inmediately afrer the skin snl-p appears ao-irpro". "[rra cooperatlon' Thts practlcehasbeenimpleEent,edlnstudtesofonchocerciaslsandlntanumberof vlllages ln OCP under the supervislon of Dr' Bayona' phorographic ident,iftcation as suggested durlng the workshop not only helps Lo reduce problem of tdenriflcliron but has beeo shown in other onc_hocercar sEudies to enhance iespoos" tt 2 polaroid photographs are raken, one t.o ue attactred to the daia collectlon forn and the other as a gifE to the PaElent. Free medlcal care and response and shquld vltamines Eo PregnanE communlty. 3.- ProJf, A. ; TIrEF:"',^,i"ta"r.i.iogi"tr EvaluaEion or ;:";;;^;;"?i'r Programe' ll'Il'o' Page IU 7. REFERENCES Control Frograune: Onchocerclasis Control 'ln the Volta Report of the 'Jlil;;;iv--a'""r"t"o"" lliselon' Geneva' Control Programe: Plan of Operat'lone for the^FinancLal Jolnt r.ogt"'l' iiit"i""''sriiil seslon' septeuber' B.land Parrault' ,oli, ffilt?::.t"f tf": ,'HH;::"'*::1h""'i;;;' 6ic*or*' I 7 5' L4' i.- Onchocerciasis i{iver Basin Area' r973. ocP/73'I Z.- 0nchocerciasis nn.". (I986-199I)' r985. JPC 6'6 ,._t;. ,.r","a.: Ba, 0.gBayona-celis : Reporr of rhe l"lission. ro carry out a Simple Evaluario""";r;;;;-ir" s"i"ciea vrir'gt" ri tttt r"ttto---ot""' l'1a11' Eoideniological errlrr.rftr, Unftl--OiP/W'E'O; ' O"t*"ioogoo' Burktna Faso' ottober 1985' ReporE of BpldenloroglcaL 3;;,Jll3:*i::?i::i=iii:f'ili"#f it 33':::ll'1"igas' -npraentologlcal Evaruatlon unlt]'-oipiw'u'0" i'"eta""eo'''"ti'iil ;;;;' Deternber 1985' 6.- Bayona-cerls, !1. :. *:ro"oo?:"J:l*1::l"Hi:il"'.1:lT:l:: t$);:;:;:: tirrr"-i"aluaEion in Ghana' ",:l:H;;;e:--- ouagadougo", n'lt..r;; ;;;;: FebiuarY Ie86' 7.-Bayona-Cells,},1.:ReportofEpldernlologicalEvaluationActlvltles. ,eralled nr"r,r.iilr,--ro sourhern rvory coasE. "-iiti"i1010grca1 Evalua.lon unlt. ocP/t.l'E:;ll" o'"e"aooeotl B;;kil" Faso' t'larch 1986' g.- Bayona-celis, M'i De- sole' --G'il1l o': Quellty' -control for parasirorogr".i^^-ria --i"o"o" o"Ir--io*eciion. i"i*r"; ocp teans ' and the western ExEenslon Mall Tean"' "iitulii"r"gt"'r '"ti"t-tloo ualt' ocP/vt'll'o" ;";;;;"'-october' 1e86 e.- Bavona-celrs ' !'t' i Dili1:' l.;', Bir.'"'iirk'lilltl;'n' '#ili:"':'";:iliot -cii"ittr Exaninations oiul*.r.o.. December' 1986' 10.-Bayona-Cells,M.e!41.}lanualofFleld}Jork.pr,ocedures,forthe Eprdentotoer"li'ir"irr.ioo u"*, tiiilt oitrtil- ot'tgtaoogou' Burkioa Faso' t986. erntnrure and raeks : l ' ;":'*fir.*:i:;?:'1";l!i!l:i:l"ili' ' o'l i '::1i::' H i :" iiliH e o f v e c'L o r contror. """?1"i;":;;;;-*;;";;' Januarv 1e86' 12.- Epldeniotogical nvaltlElon -UnIt' -99:: Report of the- Workshop orr Eoldemiorogv. 'il=; ia:='r ';;;;;' 1e86' ;;;;;dougou' Burkina Faso' rlbt"'ry' 1986 to rntervlew tlr' PangaleE li;,, lil""il::lli;"T';"'ii!:*l':i"":tiiiill'"tlsi;'i-s"'to'lio" rn ttre Farako-Slkasso ^ i"t ''" tn"-*olti"- of sept"'oti-"i"d october- 1985' Bobo Dioulasso. npral'iirolr"tr'"t'il"i'o"-u"il' ociTll'u'o" August' 1985' r4.- De sore, G.; Ba, o.,r"Il,'i"T;;.lir"'irit";:: -i"""ai*"t;.:il:' lI:": iirri" Evaluation Survey --'1. "#;1"-iepteroberlocEober, I9E5' j pi demio 1o gi., r-i;, rl,"t i o' u.rr,"Eiil --i.pt"'uerlocEober' 8 Page 1l l5..EpidenlologlcalEvaluationandVectorControlUnlts:Prellnlnary proposal for The Farako Pr-oiect on Repopulatlon of the vecEor ln a ltnlted Area. March, I986. 16.- TruetE, J.; Cornfleld, J';Kannel' W': A multlvarlate analysls of the rlskofcoronaryheart,dlseaseinFramlnghpm.JournalofChronlcDlseases L\.-Breslow,N.E.:TheproportlonalHazards},lodel:Aplicatlonsln Epidemlology. Coum. Stat'-Theor' Meth' N ' 315-332" 18..Lee'E.T.:StatlsticalMet'hod.aforSurvlvalDa!1^lnalysts.Llferlne Learnlng Publications. Behuont, Callforn!'a' U'S'A' 1980' ig.- Llllenfeld, A.M.; Llllenfeld, D.E.: Foundatione of Epidenlology' Second Edltlon. Oxford Unlverslty Press' New York' '1980' I am verY grareful uo all OCP- ".1"""u'v i::Ir::" "?:"u;"tSoecial aPPrec'l4 :'-;";;-";l'i'" "'a rriendshlP' L am indeb':d-::. :I"-:iT::t?:;;:i";.:tof the South-Eas' for OCP. ACKNOWLEDGEMENTS sraf f f or their Ht:'"::litli;"tilli"Ijrll mv actlvltles _ t".1--T":;.".,i.rouf f or their ao-'rnl-rtr Professional Personnl the CenEre for Ecological Research allowlng me II '"iii";"reave to work 8. 9. APPENDIX _ .i.f,\^/' s:; i\ i -rli\ t-. /o 't\ .t *\__, .,,,*--/v Eo H,ia' / ,/ -) c-t --). .l(?t_\)' ^t .\- \1 ' '., jl ,. .t tfn 'l) i- -i o'./- - ) !)/.il fM\)rt4A; \ ," tt.'g-'^\,r-, \\' 'H---Y..-\ ]' n 'R-s 'l '/ br,o\i* @t 4")o ) a =a co 7tOI ) th2 o u.l o\ Eh4lr O Oz ') & Fz cO tF =) ! O-\ E Voox t. ( \ -t /t-N .i.,^4.,I / I v' -\ r'r' '-r^'--*'1 \ ,-ri,+--' rt'l)rit\.\ - ,T il ._ll ii ,l ''11 iill -T +ll _u -I tL 1', rY 8.,a ,!q* '-;L /@ N { /d ( I t)i / --- ') ,.- *t' --\-r .'---'("'r" + t ,\ ) t v--/ <r-d,, \ \ -'>. ( ), o ) \. ty''- -.^-"D + oq' aJq ^\ o\l \-'- '+"'A>h\it\ -\ Y'tA I<.rlj}-*' \\Ir\\ rl\--_. ii \-/'-,i I I ".--- I\I . \ (-l-. ,)\'l-? ..t.1 _ _l .1, F..- U/ .\- m 'ti t + **J * (\ f-,ra I t I II + + + r+ -r+ + x*i'l |\ lMicEi 'rrl-\tp /,