Ivermectin distribution in northern Sierra Leone: mission 1

IVERMECTIN DISTRIBUTION IN NORTHERN SIERRA LEONE (MrssroN r) 1. Introduction Between 1st and 22nd February,1993, ivermectin distribution was carried out on a large scale in the North of Sierra I*one along two important river basins - the KABA and MABOLE rivers. The distribution was carried out by the National Onchocerciasis Control Unit of Sierra I-eone, assisted by an eJternal team of seven male nurses from the Ministry of Health. Also involved in the distribution were a two member team (one doctor and one OCP technician from Mali) and a consultant from Ghana. Prior to this, a prospection study had been carried out to identiff communities close enough to breeding sites and which were likely to suffer from onchocerciasis because of their close proximity. This was the first time ivermectin was being distributed in this area. The treatment area, restricted to villages within 10 km distance either side of the rivers had been divided into seven zones to facilitate easy distribution of the drug. Each of the seven zones was to be headed by a technician from the National OnchocerCiasis team assisted by the seven nurses from the Ministry of Health. The seven teams thus created were to commence treatment in all the seven zones at the same time. This arrangement, however, had to be altered to accommodate two important research activities on ivermectin treatment. Three of the teams had to be put together to undertake the research activities. Consequently, zones 2 and 4 could not be treated. (See attached map, Appendix I for details, study villages have been circled). 2. Research Activities Two research activities were built into the February ivermectin distribution programme. These were : 2.7. To determine a practical method for estimating dose for ivermectin treatment devoid of the use of scale. Weighing individuals to determine the dose of ivermectin required is fraught with many practical problems. The harsh environmental situations undeiwhich the sciles are handled during large scale treatments render these scales faulty in no time. They may break down completely. Many developing countries which require to treat tens of tirousands of oncho infected individuals are already struggling with their health budgets. Such countries may find continued provision of large numbers of scales for oncho treatment intolerable. This may lead to a breakdown in scheduled treatments, or continued use of old faulty scales to deliver wrong dosages to individuals. 2.2. To determine patients perception of the effects of ivermectin treatment. a EPI/88/93 1993 2This latter study is aimed at assessing objectively the perceived beneficial effects patients claim to have after taking ivermectin. It was to be done through the administration of a well structured questionnaire. To construct such a questionnaire, it was found necessary to undertake a pilot study on communities that have received ivermectin treatment before to supply the needed information. The third study, entitled "Pilot study on the perception of the effects of ivermectin treatment" was therefore undertaken in Northern Sierra I-eone on tho Rokel river basin and on the Mabole river basin outside thg treatment area for that purpose. 3. Study populations 3.1. Selection of villages for study. Accessibility, size of villages and proximity to river basins were three important considerations taken in the selection of the study populations. The following twelve first line villages with estimated populations ranging between 100 and 400 were therefore selected. i. ll. iii. lv. v. vi. vii. viii. ix. x. xi. xii. Mabebana Mamboi Gbonkomakai Kukuna Rochin Kalamgba Mamaria Mapema Makete Mamoni Magbaikule Malama 400 350 t20 t20 100 350 130 110 200 200 200 203 " 3.2. Onchocerciasisprevalencedetermination. Except for Malama with a known prevalence rate of 64.7Vo, the rates for the re-maining villages were not known. Determination of prevalence rates for the remaining villages was therefore undertaken prior to ivermectin distribution. Thirty males aged 20 years and above in each village were selected by simple random sampling and skin iniped to determine the prevalence rates. The following rates were obtained. l. iii Mabebana - 60.0Vo ii. Gbonkomakai - 86.7Vo iv. Mamboi Kukuna - 60.0Vo - 83.3Vo t 3v. vll. ix. xi. Rochin Mamaria Makete Magbaikule - 80.0Vo - 63.3Vo - 83.3Vo - 73.3Vo vi. Kalamgba viii. Mapema x. Mamoni - 80.0Vo - 76.7Vo - 76.7Vo 4. Methods. The two studies were undertaken in the same populations side by side. 4.t. Patients perception of the effects of ivermectin treatment. I Three different cells were creaied for this study. Individuals in the first cell received ivermectiq the second received mebendazole as placebo, and the third ivermectin or placebo roughly in equal proportions. Simple random sampling was used to assign drug categories to the different cells. Before administering the d*g, a questionnaire on knowledge, attitude and practices w:rs administered to all people aged 15 years and above(Appendix 2). In populations where individuals received either ivermectin or placebo, simple random sampling was used to deterrnine whether odd numbered families or even numbeied families should receive ivermectin 4.3. Study cells - Based on estimated populations and onchocerciasis prevalence rates, the following cells were selected for the study. Group A (Cell No.l) - With an estimated population of 790. l. rll l. ul. Gbonkomakai Makete Rochin Mapema Malama Kukuna Mamboi Mamaria Magbaikule Mamoni. ll. iv. Group B (Cell No.2) - With an estimated population of 750. i. Kalamgba ii. Mabebana. Group C (Cell No.3) - With an estimated population of 940. ll. iv vlv Group A was to receive ivermectin, Group B mebend azole (placebo) and Group C mixed treatment. The six national technicians were assigned to the study villages. When they finished with the work in these villages they moved over to help the othei nurses who had irt the I 4mcan time been detailed to start treatment in the non study villages. Even though a list of the study villages had been provided to all teams and asked to stay clear of these, one team inadvertently treated Mabebana and Magbaikule from Group B and group C respectively. This necessitated re-iurangement of the cells. Thus, the final study groups were: Group A (Cell 1) - With estimated population of 790 i. Gbonkomakai ii. Kukuna iii. Makete iv. Mamboi Group B (Cell 2) - With estimated population of 780 , ll. iv l. iii. Kalamgba Mamaria Rochin Malama Group C (Cell 3) - With estimated population of 320 i. Mamoni ii. Mapema. Group A received ivermectin, Group B placebo and Group C mixed treatment. The treatment regimen was made blind to the patients as well as to the interviewers. This was to ensure that the interviewers were not biased in their subsequent interviewing of treated individuals regarding-the perceived benefits of ivermectin intake. Administrati-on of drugs was therefore carried out by the consultant and the OCP/EPI medical officer from Ma[. Four weeks after the treatment, a questionnaire on perceived benefits from ivermectin will be administered to the same populations by the same original interviewers. Three months after the initial treatment the populations that received ivermectin will now receive placebo, and those that received placebo will receive ivermectin. The populations will again be interviewed one month after this second treatment about their perceived health improvement. The creation and use of the third or mixed treatment cell is to determine whether or not beneficial effects s.Rqken of by people who have taken ivermectin in the same village will have psychological influence on, and make those who have taken placebo "*p..-r,similar benefits. 5. Determining a practical method for estimating dose for ivermectin treatment. 5.1. Qbiectrve - The objective of the study wzls to determine the dose of ivermectin by using visual assessment of physical appearance of individuals to receive ivermectin a 55.2. Methods. The assessment was undertaken independently by two technicians of the National Onchocerciasis team who had previously taken part in large scale ivermectin treatment, and two villagers in each of the study villages. Most of the villagers were found to be illiterate. Nevertheless, they were made to make their assessments which were put down unedited by trvo technicians detailed to do that. t 5.3. Training. Four villagers were selected from each village on the evening preceding the day of treatment. They were given about 30 minutes basic education about who should receive and who should not receive ivermectin. For those to receive ivermectin, they were taught how to estimate the required number of tablets based on physical appearance. This was followed by practical demonstration of categories of individuals who should not receive and those who should receive various doses of tablets. On the morning of treatment, the four were tested and the best two selected to do the assessment. Preference was given to those who have received formal education in selection for training. In tno villages, however, the illiterates performed better and were selected for the assessment. 5.4. Study population. The study population was made up of all individuals present in the village on the day of treatment. 5.5. Strategy for assessment. Census of the villages was as much as possible carried out on the night preceding the day of drug administration. A list of each family, with place identification, wai providet on Form DI 02. There was one form to each family. The information on Form OiOZ was now transcribed onto a set of four Form DI 03 (Dosage estimation survey sheet. - Appendix 3 and 4). Thus, each family had one Form DI 02 and four Form DI 03. Where regiistration was not complete during the night, it was continued in the morning of the day of tieatment. Seven stations were then set up as shown below for dose estimation and treatment. I 1 2 3 4 6 Census Village Assessor I Village Assessor II Technician Assessor I Technician Assessor II Pre-treat. Interview t Weighing and treatment On the treatment day, assessori in stations 2 - 5 were provided, one each, with form DI 03, (ie. the dose assessment sheet) for each family. As families now moved from one station to the other, the assessors wrote down independently the number of tablets they would give based on the physical appearance of the patient. From the last assessor, families moved on to station six where those aged 15 years and above were interviewed, then finally to the last station for weighing and treatment. Those interviewed in station 6 carried their interview forms to station 7. To eliminate as much as possible information filtering from one assessor to the other, thesc stations were placed far apart. In some instances, the stations spanned the entire Iength of the village. 6. Pilot study on the perception of effects of ivermectin treatment. 6.1. Methods. Three villages, one on the Mabole river outside the research area, and 2 on the Rokel river, were identified for administration of the questionnaires. These villages have received treatment from Lunsar eye clinic, a non Governmental organization of thi Baptist Mission Church. Whereas some of the villagers have received ivermectin only once, ot'h.rt have received multiple treatments. Our interviews therefore covered both groups of people. 7. Results. 7.1'. Introductioq - At this stage, only part data and analysis can be presented. Data on dose assessment will be available later. However, data on perception of beneficial effect to ivermcctin treatment can only be available when the study is over in some 5 months from now. 7.2. Pilot study. There was an afiay of responses. However, the most important in which more than ten percent of the responses fell were: I 5 6 7 71. Reduced bodily pains 2. Increased skin irritation. 3. Head aches 4. General bodily pains 5. Improved vitality Other important categories are as shown in appendix 5. These responses have been incorporated in the structured questionnaire to be administered to the just treated study populations. 7.3. The following tables give analysis of the populations handled in the study villages. Table I - Group A (Cell 1) Villages treated with ivermecrin. Village Total Population No. treated Vo coverage No. interviewed Rogbonko 2M 147 72.t 103 Kukuna 138 100 72.5 73 Makete t20 76 63.3 51 Mamboi 288 180 62.5 743 Total 750 503 67.1 376 Table 2 - Group B (Cell 2) villages treated with placebo. Village Total Population No. treated Vo coverage No. interviewed Kalamgba 185 119 64.3 77 Rochin 146 91 62.3 67 Mamaria 195 11,9 61.0 93 Malama 215 150 69.7 102 Total 74t 479 64.6 333 I 8Table 3 - Group C (Cell 3) Villages with mixed treatment. Village Total Population No. treated Vo covetage No. interviewed Ivermectin Placebo Mapema 154 481lM s8/106 68.8 65 Mamoni 76 2s/s7 321s7 75.0 ' 50 Total 230 73 90 70.9 115 8. Discussion. 8.1. Distribution of ivermectin TWo of the seven zones earmarked for treatment in February 1993 could not be covercd due to the large size of the aree and the onset of Ramadan. These two zones will however be covered in April 1993. .There were no severe adverses reactions and the minor ones necded no specific treatment. Details of the results of the ivermectin distribution will be provided in a later report. 10. Acknowledgement. amvQrygrateful to DrE.M. Samb4 Director of OCP and Dr Boakyi Boatin, Chief 9f E-PI for making it possible for me to be associated with ivermectin distribution inNorthcrn Sierra Leongt I am grateful also to Dr A. R. Wurie, Nationai Co-ordinator of onchoccrciasis Control in Sierra Lrone, Dr. I. F. Jalloh of the National Control Unit, SieriaI-eone, Dr. N. Demb6l6 from EPI, Mali and all the technical officers unA arir"ir;h;i;6;; to make the research and treatment successful. Dr L. Osei Consultant/Epidemiologist. a Appendir I - r-\ s :JI \ ar- =tg 06o - oc o E o .o ot E o -J o Ela, o oI - o -- a / o6 'o - / \, oc I I o to aq, L o \$ Eo oE .q' b ",EPoE-Oco=.- =o!'; 3iE .E I Ey,;,q:tr€Y.:I\)II !tll \ I ,a a a t a a o o6 o - I I t C o b E \ \t O '!p o Ea o a a\: t-8 e1 .s I 7 I UJz o LrJJ E E, !r o o =a (D tr lr, : tr t!J o(D =o z { m Y tL o L = a a aa a a \-- E o @c Et G ooo E o Ev o \ a a , a a \ a a a a \ \ \ \ \ /( \I ,IJ J 0 Dox / \ \ oF E fu a- 8 Ico o o 4 I lta E = / / I / / -/ / // \ \ a \ a\ \ \ \ \ \ Appendrr 3 Od .9 Itt6 o vt ocr atr , art ae c{ .aE- CQao r3 ate 2, ag E o 00I x3 r E It,t r I 3 Eaz dz (r, 5() fl s t Eiloh I.5 c :, 3 E a EI ta Eah I 2,o t-b E la o r{ dbrslL EEqt= >itr> 58fr\ <-IF<<iJEAol 2eItrI tI Appendir $ oc o (6 a oo .o o I I i .t o6 o) -o(o(Ua-oooz , ooc(d(! ooo I xoa iii ,- :l(l)I'-o >E ZZ Ir oclL(6I cl iEJt :: 1)c o!o o' (f)(\t lr,$ @ @ G)l() I I I I (\I I oo q) o) +i(6-iE:F I I I I I H i"lEl__J E] o =o).E o s [-]erq o C" -o .-ca C' d) o .>E LtJ G =a 2IF !E tra IJJ UJ o a o o F2 IJJ =F ultt- . F o UJ =G IU z I UJ = =G o oGr J o cE z -J 9,o =<o E, uJ o ot oz o o (o o o -o Efz5 E(! TL E (U BBcl oo , oN. I Appendix 5 PERCEPTION OF THE EFFECT OF IVERMECTIN TREATMET{T RESPONSES SYMPTOMS Reduced bodily pains Increased skin irritation Headaches General bodily pains Increased vitality Improved vision Passed wor[$ Dizziness Skin irritation stopped Joint pains Improved sexual activity Palpitation No more fevers Scabies healed Bone Pains General weakness Swelling of the body Blurred vision Reduced toothache Cough . Development of skin lesions Muscle twitching " Reduced asthma attacks Reduced nodule size Free bowels Cough stopped FREQUENCIES 24 15 L2 t2 9 , 8 7 7 7 5 5 3 3 3 3 3 2 2 2 2 2 2 2 2) 2 I